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1 


STRICTURE   OF  THE  RECTUM: 


A  STUDY  OF 


ONE    HUNDRED    AND   THIRTY-EIGHT   CASES. 


iijecmxit  Edition:  %u\kkqz&,. 


CHAS.    B.    KELSEY,   M.D., 

NEW  YORK, 

Professor  of  Diseases  of  the  Rectum, at  the  New  York  Post- Graduate  School  and 

Hospital  ;  late  Professor  of  Rectal  Surgery  at  the   University  of 

Vermont,  etc.,  etc. 


STRICTURE  OF  THE  RECTUM. 


For  convenience  of  study  the  following-  classification  of 
the  different  varieties  of  stricture  of  the  rectum  has  been  ar- 
ranged. It  is  intended  to  include  all  the  possible  forms  of  the 
disease. 


Acquired. 


Congenital. 


Complete. 
Partial. 


I  1.  Spasm. 

I  2.  Pressure  from  without. 

I  3.  Non-venereal. 


4.  Venereal. 


5.  Cancer. 


Dysenteric. 
Tubercular. 
Inflammatory. 
Traumatic. 

Ulceration  (either  chan- 
croidal, secondary,  or  ter- 
tiary). 

Due  to  unnatural  vice. 
Neoplastic.     (Grummata. 
Ano-rectal  syphiloma.) 


The  first  great  division  is  into  the  congenital  and  acquired, 
and  the  congenital  may  be  subdivided  into  the  complete  and 
partial  with  practical  advantage,  inasmuch  as  the  former 
require  immediate  relief  to  prolong  life,  and  the  latter  may 
exist  for  many  years  without  causing  fatal  results  or  in  some 
cases  even  being  detected.  A  more  exhaustive  description  of 
the  several  varieties  of  congenital  malformations  will  be  found 
in  my  general  work  on  diseases  of  the  rectum. 

Of  the  acquired  strictures  the  rarest  is  the  spasmodic;  but 
of  its  occasional  existence,  and  almost  invariably  in  associa- 
tion with  some  other  disease,  there  can  no  longer  be  any  doubt, 
though  the  fact  has  been  questioned  for  many  years.  I  have 
never  seen  it  in  an  otherwise  healthy  rectum,  but  I  have  seen 
it  present  to  a  marked  extent  once  in  connection  with  a  slight 
organic   stricture  and   again  with  hemorrhoidal  ulceration. 


4  Stricture  of  the  Rectum. 

In  the  latter  case  it  was  so  marked  as  to  render  the  introduc- 
tion of  the  finger  impossible  till  after  the  administration  of 
ether,  when  it  entirely  disappeared. 

Any  form  of  pressure  from  outside  the  rectum  may  he 
sufficient  to  occlude  it,  but  generally  the  pressure  will  be  due 
either  to  a  cancerous  growth  or  pelvic  cellulitis.  In  one  of 
my  cases  the  pressure  of  a  cancerous  mass  springing  from  the 
promontory  of  the  sacrum  first  manifested  itself  by  causing 
complete  and  almost  fatal  occlusion.  The  patient  was  relieved 
by  a  colotomy  done  in  the  midst  of  acute  peritonitis  with  the 
happiest  result.  In  two  other  cases  the  pressure  was  due  to 
the  presence  and  contraction  of  old  pelvic  exudations.  One  of 
these  was  fatal  from  heart  and  kidney  complications,  after  an 
attack  of  complete  obstruction  had  been  overcome  by  opium 
and  frequent  tappings  of  the  distended  gut;  the  other  was 
completely  relieved  by  colotomy. 

Non- venereal  stricture  may  be  either  dysenteric,  tubercular, 
inflammatory,  or  traumatic. 

Dysenteric  strictures  are  not  very  uncommon  in  New  York, 
though  generally  seen  in  patients  coming  from  warmer  climes. 
As  I  have  seen  them  they  have  been  severe,  the  ulceration 
being  extensive,  and  the  cicatricial  contraction  considerable 
in  amount. 

Tubercular  ulceration  can  only  be  diagnosticated  from  the 
general  condition  and  history  of  the  patient,  and  by  examina- 
tion for  the  bacilli  under  the  microscope. 

Inflammatory  stricture,  due  to  the  destruction  of  a  consid- 
erable amount  of  peri-rectal  tissue  by  acute  inflammation,  is 
rare.  That  it  may  occur  at  any  time  as  the  result  of  a  large 
abscess  or  extensive  sloughing  is  undoubted. 

Any  severe  form  of  proctitis  resulting  in  ulceration  may 
be  a  cause  of  stricture.  Such  a  proctitis  may  result  from  the 
mechanical  effects  of  a  fascal  impaction;  from  pressure  arising 
from  malposition  of  the  uterus;  from  the  erosion  and  ulcera- 
tion of  baemorrhoidal  tumors;  in  fact  from  any  irritation 
sufficiently  severe  to  set  up  an  inflammation  which  ends  in 
destruction  of  the  mucous  membrane. 

Traumatic  ulceration  following  operations  or  wounds  of 
the  rectum  is  not  at  all  infrequent.  Axvy  one  who  has  watched 
the  slow  cicatrization  of  a  surgical  wound  of  the  rectum  fol- 
lowing an  operation  for  haemorrhoids  or  fistula,  knows  how 


Stricture  of  the  Rectum.  5 

easily  such  a  wound  when  neglected  may  change  into  an  in- 
tractable ulcer  and  how  surely  the  ulcer  may  develop  into 
stricture. 

The  venereal  strictures  have  always  been  a  subject  of  dis- 
cussion. 

Without  assuming-  too  much  as  generally  granted,  it  may 
safely  be  said  that  beyond  dispute  there  are  three  forms  of 
well-recognized  venereal  disease  in  the  rectum  which  may  re- 
sult in  stricture.  These  are:  First,  chancroidal,  secondary, 
and  tertiary  ulcerations  of  the  rectal  mucus  membrane.  Second, 
ulcerations  due  to  unnatural  sexual  intercourse,  either  sim- 
ply traumatic  or  the  result  of  direct  inoculation.  Third,  an 
unusual  form  of  tertiary  disease  of  the  general  nature  of  a 
gummatous  deposit  variously  described  by  different  authors, 
and  by  Fournier  in  a  Monograph,  as  "Ano-rectal  syphiloma." 

All  of  these  much  disputed  conditions  I  think  I  can  say  I 
have  nryself  seen,  diagnosticated,  and  treated. 

Last  of  all  we  have  the  all  too  frequent  manifestation  of 
cancer  in  this  part  of  the  body — a  disease  which  we  are  now 
beginning  to  treat  with  favorable  results  which  a  decade  ago 
would  have  been  thought  impossible. 

Symptoms. 

These  may  be  grouped  under  two  heads;  those  due  to 
ulceration  and  those  due  to  mechanical  obstruction.  In  the 
great  majority  of  cases  the  signs  of  mechanical  obstruction 
will  be  preceded  by  those  of  the  ulceration  which  has  caused 
it.  The  symptoms  of  ulceration  of  the  rectum  are  pain,  and 
the  discharge  of  bloody  pus.  The  pain  is  located  in  the  rec- 
tum; is  of  a  dull,  constant  character;  and  unless  the  sphincter 
is  involved  is  not  greatly  increased  by  the  act  of  defecation. 
In  addition  to  this  there  is  generally  pain  in  the  back,  scro- 
tum, loins,  and  down  the  thighs.  There  is  often  great  sym- 
pathetic vesical  disturbance,  and  loss  of  sexual  power.  The 
discharge  of  blood  and  pus  is  quite  characteristic.  When  the 
disease  is  of  limited  extent  this  occurs  only  with  the  stools, 
when  more  extensive  it  fills  up  the  rectum  and  is  passed  in- 
dependently of  the  fasces.  The  rectum  becomes  filled  with  it 
during  the  night  and  the  patient  is  wakened  early  in  the 
morning  by  the  desire  for  an  evacuation  which  results  only  in 
the  passage  of  slime  and  a  little  black  blood. 


6  Stricture  of  the  Rectum. 

After  an  hour  or  two  there  is  another  movement,  this  time 
often  containing'  fasces  mixed  with  blood  and  pus.  This  may 
be  repeated  several  times  at  intervals  of  an  hour  or  so,  and 
then  there  may  be  several  hours  of  rest.  In  an  advanced  case 
the  patient  is  deprived  entirely  of  rest  by  the  persistent  dis- 
charge; sleep  is  impossible,  and  life  is  passed  in  a  constant 
effort  to  keep  the  rectum  free  from  the  irritating  discharge. 

The  bleeding  is  not  generally  very  profuse,  and  the  patient 
seldom  passes  blood  alone;  the  discharge  generally  consisting 
of  pus  and  mucus  streaked  with  blood,  and  occasionally  of 
a  little  fascal  matter. 

In  addition  to  the  discharge,  the  symptoms  caused  by  the 
mechanical  obstruction  begin  to  show  themselves  after  a  time. 
At  first  there  may  be  only  great  straining  resulting  in  the 
passage  of  small  lumps  of  matter.  Later  the  patient  will 
complain  that  he  never  has  a  passage  without  taking  a  cathar- 
tic, and  that  he  has  adopted  the  practice  of  doing  this  once  or 
twice  a  week;  unloading  the  bowel  first  of  small  pieces  of 
solid  matter,  and  then  of  a  large  quantity  of  semi-solid  and 
liquid  fasces.  The  condition  of  chronic  obstruction  with  its 
attendant  evils — dilatation  of  the  bowel  and  intestinal  catarrh 
above  the  obstruction,  with  ulceration  and  thinning  of  the  in- 
testinal wall — is  thus  insensibly  established.  One  who  sees 
many  of  these  cases  of  chronic  obstruction  and  knows  how 
dilated  and  weakened  the  bowel  may  become  above  the  stric- 
ture will  be  very  cautious  in  the  use  of  cathartics  in  this  con- 
dition. 

Acute  obstruction  may,  at  any  time,  be  added  to  the 
chronic  condition;  but  acute  and  complete  obstruction  are 
comparatively  rare  in  stricture  of  the  rectum;  and  acute  ob- 
struction as  the  first  symptom  of  the  disease  without  the  pre- 
vious history  of  ulceration  is  rarer  still.  In  my  own  experi- 
ence I  have  seen  acute  complete  obstruction  supervene  upon 
the  chronic  condition  in  but  three  cases,  two  ending  fatally  in 
rupture  of  the  colon,  and  the  other  relieved  by  opium  and  as- 
piration of  the  distended  gut. 

Acute  obstruction  as  the  first  and  only  symptom  of  stric- 
ture I  have  seen  but  once — a  case  of  cancer  between  the  prom- 
ontory of  the  sacrum  and  the  rectum  occluding  the  latter  by 
direct  pressure.  In  one  other  case  acute  obstruction  ended 
fatally  before  there  were  sufficient  symptoms  of  rectal  disease 


Stricture  of  the  Rectum.  7 

to  enable  us  to  make  a  diagnosis ;  the  patient,  a  physician, 
complaining  only  of  pain  in  the  left  iliac  fossa,  and  of  occa- 
sional passages  of  blood  with  the  faeces.  The  autopsy  revealed 
an  annular  cancerous  stricture  in  the  sigmoid  flexure. 

All  of  these  cases  illustrate  the  general  rule  that  complete 
obstruction  is  only  liable  to  occur  when  the  stricture  is  high 
up,  and  that  it  may  then  occur  very  early  and  with  very 
slight  premonition.  In  many  old  cases  near  the  anus  it  is 
surprising  to  see  how  many  years  life  will  be  prolonged  with 
the  gut  almost  completely  closed.  The  explanation  is  purely 
a  mechanical  one— with  a  stricture  high  up  in  the  movable 
portion  of  the  bowel,  the  force  applied  in  the  effort  of  defeca- 
tion merely  bends  the  gut  upon  itself  and  increases  the  ob- 
struction by  adding  a  flexure  to  the  stricture.  On  the  other 
hand,  in  disease  low  down,  where  the  rectum  is  firmly  held  in 
place  by  bony  points,  all  the  force  of  the  expulsive  move- 
ment is  brought  to  bear  in  a  direct  line  with  the  orifice,  and 
small,  ribbon-like  masses  of  solid  faeces  are  driven  through 
the  opening  as  long  as  any  opening  remains.  This  is  the  ex- 
plantion  of  tape-like  stools  as  a  symptom  of  stricture.  They 
are  only  seen  when  the  disease  is  near  the  anus,  and  they  are 
often  caused  by  a  spasmodic  action  of  the  sphincter  where 
there  is  no  organic  stricture. 

Stricture  of  the  rectum,  whether  cancerous  or  benign,  left 
to  its  own  course,  ends  fatally,  either  by  obstruction  or  by  ex- 
hausting the  sufferer's  powers.  After  a  few  years  these  pa- 
tients sink  into  a  miserable  condition,  worn  out  by  constant 
rectal  tenesmus,  by  chronic  inestinal  obstruction,  and  by  de- 
generation of  the  kidneys.  The  only  attempt  at  a  cure  nature 
is  ever  known  to  have  made  was  in  the  case  of  Talma,  where 
an  intestinal  anastomosis  was  established  above  and  below  the 
disease,  and  this  was  not  successful  in  preserving  life. 

Diagnosis. 

The  mere  diagnosis  of  the  presence  of  stricture  is  generally 
easy,  because  in  the  great  majority  of  cases  the  disease  is 
within  reach  of  the  finger  by  rectal  examination,  and,  when 
felt,  can  be  mistaken  for  nothing  else. 

When,  however,  a  patient  complains  of  the  symptoms  of 
ulceration  and  stricture,  and  no  stricture  is  found  by  digital 


8  Stricture  of  the  Rectum. 

examination,  the  problem  at  once  becomes  one  of  the  most 
difficult  in  physical  diagnosis.  There  is  one  part  of  the  lower 
bowel — that  part  which  can  be  reached  neither  by  the  finger 
in  the  rectum,  nor  the  hand  in  the  pelvis,  nor  by  both  com- 
bined— where  our  means  of  diagnosis  are  as  yet  very  uncer- 
tain; and  in  just  this  part  we  occasionally,  though  rarely,  find 
a  stricture. 

We  have  at  present  but  one  means  of  detecting  stricture 
here,  and  that  is  the  uncertain  one  of  the  rectal  bougie,  unless 
we  open  the  abdomen  and  search.  Let  me  exemplify  this  by 
one  of  my  own  cases.  The  patient  in  apparent  perfect  health 
was  sent  to  me  for  diagnosis  by  Dr.  Janeway.  He  complained 
only  of  a  little  blood  in  the  passages,  easily  accounted  for  by 
haemorrhoids;  and  of  a  pain  deep  down  in  the  left  side  of  the 
pelvis.  The  haemorrhoids  were  removed;  for  a  time  the  pa- 
tient was  better;  then  the  symptoms  were  the  same  as  before. 
Examination  in  the  left  inguinal  region  and  pelvis  showed 
only  the  sigmoid  flexure,  hard  and  round,  rolling  under  the 
fingers.  A  full-sized  rectal  bougie,  twelve  inches  long,  passed 
without  difficulty.  Even  with  this  evidence  I  could  only  say 
that  the  upper  part  of  the  rectum  would  admit  a  JSTo.  8 
rectal  bougie.  I  could  not  say  there  was  no  disease,  and  I 
was  cautious  in  my  diagnosis,  as  Dr.  Janeway  had  been  before 
me ;  merely  telling  the  patient  there  was  but  one  way  to  settle 
the  question  and  that  was  by  an  exploratory  incision.  This 
he  declined,  as  I  should  have  done,  because  the  symptoms 
hardly  seemed  to  justify  it,  and  yet  within  a  few  weeks  he  died 
of  acute  obstruction  from  annular  cancerous  stricture  of  the 
sigmoid  flexure. 

In  this  matter  bougies  are  only  of  limited  utility.  If  I 
could  pass  no  bougie  at  all  after  proper  trials,  and  if,  under 
ether,  I  still  failed  to  effect  the  passage  of  an  instrument  I 
should  not  hesitate  to  make  a  positive  diagnosis  of  a  very 
tight  stricture.  Also,  if  a  medium-sized  bougie,  say  ISTo.  7, 
passed  easily,  but  a  No.  8  could  not  be  passed,  and  the  symp- 
toms pointed  to  old  ulceration  of  the  intestine,  I  should  diag- 
nosticate a  contraction,  but  I  should  not  do  so  till  after  sev- 
eral careful  trials  with  the  instruments. 

It  would  seem  as  though  the  same  facility  in  diagnosis  in 
the  upper  rectum  could  be  reached  as  in  the  deep  urethra,  but 
it  has  never  yet  been  acquired.     Attempts  at  the  same  kind 


Stricture  of  the  Rectum.  9 

of  exploration  with  bulbous  bougies  on  pewter  stems  have 
been  made,  and  several  varieties  of  these  are  now  in  the  mar- 
ket, but  they  have  been  unsatisfactory  in  my  own  hands. 
They  are  more  difficult  to  pass  than  the  flexible  pure  rubber 
bougie,  and  when  passed  they  are  not  sufficiently  delicate  to 
detect  strictures  of  large  calibre. 

In  passing  a  rectal  bougie  the  first  obstruction  is  always 


Fig.  1.— Soft-Rubber  Rectal  Bougie. 

at  the  promontory  of  the  sacrum,  and  the  next  is  by  the  loose 
folds  of  mucous  membrane.  With  a  flexible  rubber  bougie 
the  promontory  can  be  passed  without  difficulty  or  force,  and 
by  the  injection  of  water  through  the  bougie  the  folds  of  mu- 
cous membrane  can  be  drawn  out  of  the  way  by  dilating  the 
canal,  and  the  instrument  passed  full  length.     With  the  olive- 

riGMANN-CO. ^^s. 


Fig.  2. — Metallic  or  Vulcanite  Bougie. 


pointed  bougie  on  the  metal  stem,  the  promontory  can  only 
be  passed  by  introducing  the  finger  and  lifting  the  end  of  the 
bougie  over  it,  and  beyond  this  all  is  uncertain. 

I  am  now  experimenting  with  a  distinct  olivary  point  and 
narrow  neck  on  a  soft  rubber  bougie  with  which  I  hope  to 
accomplish  something.    In  the  ordinary  bougie  the  olive  point 


Fig.  3.— Soft-Rubber  Bulbous  Bougie. 


is  too  small  to  be  of  any  use  in  diagnosis  as  is  seen  \>y  Fig.  1. 
In  the  olive-pointed  metal  bougie  shown  in  the  cut  (Fig.  2)  the 
metallic  stem  is  much  inferior  to  the  soft-rubber  bougie,  and 
any  bending  of  it  before  introducing  it  only  complicates  mat- 
ters and  makes  it  more  difficult  to  pass.  It  seems  to  me  that 
an  instrument  can  be  made  combining  the  advantages  of  both 
such,  as  is  shown  in  Fig-.  3. 


io  Stricture  of  the  Rectum. 

Still  one  other  method  of  diagnosis  is  open  to  us — the  pas- 
sage of  the  whole  hand  into  the  rectum.  This  is  impossible 
for  the  average  hand,  and  for  any  hand  is  more  dangerous 
than  an  exploratory  laparotomy.  It  requires  an  exceptionally 
small  and  narrow  hand  to  practise  this  manoeuvre  with  any 
degree  of  safety. 

Should  exploratory  incision  be  decided  upon,  it  should  be 
made  as  for  left  inguinal  colotomy,  in  order  that  an  artificial 
anus  may  be  established  at  the  same  time  should  a  stricture 
be  discovered. 

On  the  whole,  then,  we  can  say  that  the  mere  diagnosis  of 
the  existence  of  stricture  in  the  lower  part  of  the  rectum  is 
easy,  and  beyond  the  reach  of  digital  examination  very  diffi- 
cult. After  the  presence  of  stricture  has  been  decided  upon, 
the  determination  of  its  character  may  also  be  a  matter  of  great 
difficulty. 

The  first  great  point  to  be  decided  is  between  cancer  and 
non-malignant  disease. 

There  is  an  old  and  deeply  rooted  idea  in  the  minds  of  the 
profession  that  a  stricture  of  the  rectum  must  be  either  can- 
cerous or  syphilitic — an  idea  founded  on  error  and  capable  of 
doing  much  harm  and  injustice  to  people  innocent  of  any 
sexual  irregularities.  Again  and  again  I  have  been  able  to 
give  great  comfort  to  women  suffering  from  this  disease  by 
disputing  the  correctness  of  this  idea;  and  in  my  own  practice 
the  fact  that  a  stricture  is  not  cancerous  adds  little  weight  to 
the  idea  that  it  may  be  syphilitic. 

In  the  collection  of  cases  given  at  the  end  of  this  article  it 
will  be  seen  that  of  all  non-malignant  strictures  only  a  small 
proportion  were  palpably  venereal.  Any  of  the  gentlemen 
who  have  followed  my  clinic  for  any  length  of  time  will  agree 
that  the  proportion  of  venereal  strictures  of  the  rectum  is 
much  smaller  than  they  expected  when  beginning  the  study ; 
and  I  use  the  word  venereal  intentionally  to  cover  not  only 
syphilis,  but  all  possible  diseases  arising  from  the  sexual  act 
or  its  abuse. 

Outside  of  cancer  and  venereal  disease  I  have  in  the  table 
enumerated  the  following  varieties  of  stricture :  Congenital ; 
spasmodic;  those  due  to  pressure  on  the  gut;  dysenteric;  tu- 
bercular; inflammatory;  and  traumatic.  Each  of  these  causes 
must  be  allowed  its  full  weight  in  determining  the  nature  of 


Stricture  of  the  Rectum.  II 

any  particular  case,  for  none  of  them  are  so  rare  that  they 
can  he  safely  neglected. 

To  make  the  diagnosis  as  to  the  exact  nature  of  a  stricture 
may  in  some  cases  be  impossible,  but  there  are  certain  facts 
which  will  be  found  of  great  assistance. 

As  a  first  step  in  the  differential  diagnosis  between  malig- 
nant and  non-malignant  stricture  the  length  of  time  the  dis- 
ease has  existed  is  of  great  practical  help.  Cancer  of  the 
rectum  generally  runs  its  course  in  two  or  three  37ears.  When, 
therefore,  a  patient  says  stricture  and  ulceration  have  existed 
ten,  fifteen,  or  twenty  years  a  great  point  has  been  gained. 
When,  on  the  other  hand,  a  middle-aged  patient  says  that 
the  symptoms  date  back  only  a  few  months,  and  an  examina- 
tion reveals  masses  of  hard  tissue  occluding  the  bowel,  with 
more  or  less  destructive  ulceration,  the  disease  can  hardly  be 
other  than  malignant.  By  careful  attention  to  the  history 
alone,  the  nature  of  the  affection  can  thus  very  often  be  de- 
termined. 

In  other  cases  digital  examination  alone  is  sufficient  for 
the  differential  diagnosis,  Generally  cancer  in  the  rectum 
presents  itself  to  the  sight  and  touch  as  a  mass  of  stony  hard- 
ness, nodular,  irregular,  and  without  pedicle;  growing  in  the 
substance  of  the  rectal  wall  and  involving  all  adjacent  tissue; 
with  no  tendency  to  isolate  itself  and  hang  free  in  the  cavity 
of  the  gut.  More  rarely  it  is  seen  in  the  form  of  a  deep  ulcera- 
tion with  hard  floor  and  raised  hard  edges — an  ulceration  so 
pronounced  and  so  destructive  as  to  leave  no  room  for  doubt 
as  to  its  nature.  Again  it  not  unfrequently  presents  itself  as 
a  bleeding,  fungous  mass  involving  the  whole  substance  of  the 
rectal  wall,  filling  and  occluding  the  gut,  and  perhaps  extrud- 
ing at  each  act  of  defecation. 

In  either  of  these  three  clinical  forms  the  gross  character- 
istics are  diagnostic,  and  with  experience  it  is  not  generally 
difficult  to  decide  between  malignant  and  non-malignant  dis- 
ease. The  cases  most  doubtful  are  those  where  the  rectum  is 
occluded  by  dense  masses  of  fibrous  tissue — dysenteric,  vene- 
real, or  resulting  from  simple  ulceration.  In  these  the  amount 
of  disease  may  be  as  great  as  or  greater  than  in  cancerous  in- 
filtration, and  the  hardness  to  the  touch  may  be  the  same;  but 
the  history  of  the  case  and  the  length  of  time  it  has  existed 
will  generally  solve  the  question. 


12  Stricture  of  the  Rectum. 

Enlarged  glands  in  the  groin  or  hollow  of  the  sacrum  are 
of  great  value  when  found,  and  we  always  have  the  micro- 
scope to  appeal  to  in  case  of  doubt. 

I  would  not,  however,  give  the  impression  that  this  diag- 
nosis between  benign  and  malignant  disease  can  always  be 
made  absolutely,  either  by  the  history  or  by  digital  examina- 
tion, for  such  is  not  my  experience,  and  I  am  occasionally  very 
glad  to  secure  a  piece  of  the  growth  for  microscopic  examina- 
tion before  committing  myself  to  a  positive  diagnosis.  The 
following  statement  by  Allingham  has  always  represented  to 
me  a  wonderful  clinical  experience.  He  says:  "There  is  some- 
thing peculiar  about  the  feel  of  cancer,  which  the  practised 
finger  rarely  mistakes  even  for  simple  indurated  ulceration. 
I  think  it  is  many  years  now  since  I  mistook  the  one  for  the 
other.  There  is  also  a  peculiar  odor  which  one  cannot  de- 
scribe, but  which  once  recognized  will  rarely  be  forgotten.  In 
my  opinion  the  odor  is  pathognomonic."  This  odor  of  cancer 
I  have  never  been  able  to  distinguish  as  anything  diagnostic, 
and  I  confess  to  a  feeling  of  relief  when  in  Cripps's  monograph 
on  this  subject  I  find  that  he  also  appreciates  that  in  some 
cases  the  diagnosis  may  be  difficult. 

Greater  difficulty  may  be  found  in  the  differential  diagnosis 
of  the  different  forms  of  non-malignant  stricture  from  each 
other,  than  in  deciding  the  first  great  question  of  cancer. 
Dj^senteric  contraction  is  known  by  the  history  and  often  by 
the  extensive  character  of  the  fibrous  induration.  Tubercular 
disease  may  first  be  suspected  from  the  patient's  general  con- 
dition, from  the  coexistence  of  lung  trouble,  or  the  family  his- 
tory; and  the  diagnosis  may  then  be  confirmed  under  the 
microscope.  In  congenital  stricture  in  adult  life  the  existence 
of  a  knife-edge  constriction  without  ulceration  or  induration  is 
diagnostic.  Strictures  resulting  from  slight  traumatism,  such 
as  operations  for  haemorrhoids,  may  be  recognized  by  the  ab- 
sence of  any  other  exciting  cause,  as  syphilis,  and  by  the  his- 
tory of  long-continued  ulceration. 

The  moment  we  attempt  to  say  positively  that  any  stric- 
ture is  or  is  not  of  venereal  origin  we  begin  to  trench  upon 
the  unknown. 

In  the  collection  of  cases  which  forms  the  basis  of  this 
article  some  have  been  classified  as  syphilitic,  and  I  have  no 
doubt  of  the  correctness  of  this  diagnosis;   but  were  I  forced 


Stricture  of  the  Rectum.  13 

to  give  the  reasons  for  this  belief  I  could  only  say  that  these 
patients  had  other  well-marked  signs  of  syphilis,  and  that  the 
stricture  was  of  a  type  which  I  have  come  to  consider  as  in- 
dicating a  syphilitic  origin.  The  test  of  treatment  does  not 
apply  in  these  cases,  for  neither  mercury  nor  iodine  has  anjr 
effect.  We  know,  however,  beyond  question,  that  chancroids, 
late  syphilitic  ulcerations,  and  gummatous  infiltrations  do 
occur  in  the  rectum,  and  do  cause  extensive  strictures;  and 
where  no  other  cause  can  be  found,  and  there  is  a  reliable 
venereal  history,  we  are  justified  in  attributing  certain  stric- 
tures to  these  causes;  but  we  are  not  justified  in  considering 
venereal  disease  as  accounting  for  all  cases  of  otherwise  doubt- 
ful origin.  In  my  table  I  have  put  down  almost  as  many 
strictures  as  positively  non-venereal  as  have  been  included 
among  the  venereal,  and  a  number  more  as  undetermined. 
In  the  former  cases  I  was  firmly  convinced  that  the  patient 
had  never  had  venereal  disease,  and  in  the  latter,  a  doubtful 
venereal  history  had  no  more  weight  with  me  in  the  diagnosis 
than  any  other  of  the  possible  causes. 

Among  the  venereal  strictures  as  distinguished  from  the 
syphilitic,  cases  will  occasionally  occur  in  which  the  possible 
causative  influence  of  unnatural  sexual  vice  must  be  consid- 
ered. In  my  table  there  are  two  of  these,  one  in  a  man,  the 
other  in  a  woman,  both  of  whom  acknowledged  the  practice. 
In  both  the  vice  was  of  long  standing  and  in  both  there  was 
ulceration  and  contraction;  but  whether  simply  traumatic  or 
due  to  infection  there  was  no  way  of  deciding.  In  one  the 
stricture  was  of  considerable  extent,  and  from  its  probably 
malignant  nature  I  extirpated  it  with  good  result  as  to  both 
subsequent  stricture  and  incontinence.  Examination  of  the 
specimen  under  the  microscope,  however,  showed  nothing  but 
a  very  unusual  amount  of  fibrous  tissue. 

Treatment. 

The  greatest  advances  in  the  surgery  of  the  rectum  have 
been  made  during  the  past  decade  in  the  treatment  of  stricture. 
Cases  which  a  few  years  ago  were  allowed  to  die  without 
surgical  aid  are  now  made  perfectly  comfortable;  and  opera- 
tions which  were  then  considered  as  hardly  justifiable  are 
now  of  daily  occurrence  and  give  the  happiest  results. 


14  Stricture  of  the  Rectum. 

The  means  at  our  command  for  the  treatment  of  this  affec- 
tion are:  1.  Dilatation;  2.  Incision;  3.  Partial  Destruction, 
including-  Electrolysis  and  Raclage;  4.  Excision;  5.  Colotomy; 
6.  General  Treatment. 


Dilatation. 

This,  either  alone  or  in  connection  with  incision,  is  one  of 
the  most  reliable  agents  for  the  treatment  of  this  disease. 
By  dilatation  I  mean  gradual  stretching,  not  forcible  divulsion. 
The  latter  is  a  justifiable  procedure;  one  which  under  certain 
conditions  may  accomplish  great  good,  but  one  seldom  ap- 
plicable. 

Whether  dilatation  be  practised  as  an  independent  method 
of  treatment  or  as  a  supplement  to  division,  it  should  always 
be  practised  in  one  way.  Nothing  is  productive  of  more  evil 
than  forcing  a  bougie  through  a  stricture  when  the  instru- 
ment is  too  large  to  be  passed  without  pain  and  violence,  and 
no  good  is  ever  accomplished  in  this  way.  A  bougie  that  is 
large  enough  to  cause  pain  by  stretching  is  always  too  large 
to  do  anything  but  harm. 

The  instrument  best  adapted  for  this  purpose  is  the  soft 
rubber  one  shown  in  Pig.  1,  A  size  should  be  selected  which 
will  pass  through  the  stricture  without  force  and  which  may 
be  left  in  place  several  hours  without  causing  uneasiness.  In 
this  way  absorption  of  the  stricture  tissue  may  be  caused,  and 
great  benefit  may  result.  It  is  a  well-known  fact  that  if  the 
smallest  filiform  bougie  be  passed  through  a  stricture  of  the 
urethra  and  allowed  to  remain  for  a  day  or  two,  a  much  larger 
size  can  then  be  substituted  for  it,  and  the  same  is  true  of  the 
rectum*  Any  instrument  the  introduction  of  which  causes 
pain  will  soon  cause  so  much  irritation  as  to  render  its  use 
impossible;  while  with  gentleness  and  time  most  non-malig- 
nant strictures  may  be  greatly  benefited. 

M}r  own  rule  is  to  select  an  instrument  which  can  be  left 
in  place  several  hours,  often  all  night,  and  to  introduce  it 
daily.  When  the  disease  is  so  high  up  that  the  long  bougie 
is  necessarj',  its  introduction  should  never  be  left  either  to 
patient  or  nurse;  for  even  with  the  soft  rubber  one  mentioned 
great  harm  may  be  done.  In  cases  where  the  disease  is  nearer 
the  anus  I  have  had  these  same  instruments  made  five  inches 


Stricture  of  the  Rectum.  1 5 

long-  instead  of  twelve,  and  these  may  safely  be  entrusted  to 
the  patient.  They  are  numbered  in  sizes  from  one  to  twelve 
(Fig-.  4). 

The  treatment  by  gentle  dilatation  will  accomplish  most 
in  cases  of  limited  severity  and  as  a  supplement  to  the  treat- 
ment by  incision  or  excision.  Some  of  the  old  fibrous  strictures 
are  too  extensive  to  be  relieved  in  this  way,  and  in  malignant 


Fig.  4.— Short  Bougie  for  Dilalation. 

disease  it  can  do  little  if  any  good — the  disease  steadily  ad- 
vancing. A  patient  with  a  malignant  stricture  which  is 
threatening  obstruction  needs  more  radical  treatment  than 
the  bougie,  and,  except  in  case  of  threatened  obstruction,  no 
possible  good  can  be  accomplished  by  it. 

Incision. 

The  treatment  of  stricture  by  linear  proctotomy  was  intro- 
duced by  the  French  surgeons,  and  judged  by  their  first  en- 
thusiastic reports  it  seemed  that  by  it  alone  a  radical  cure 
could  be  effected.  Subsequent  experience  has  convinced  me 
that  such  is  not  the  case,  and  that,  like  the  analogous  opera- 
tion of  external  urethrotomy,  it  must  be  followed  by  dilata- 
tion to  preserve  the  channel  opened  up  by  the  knife.  As  a 
means  of  saving  time,  and  of  gaining  a  wider  passage  than  can 
be  hoped  for  from  the  bougie  alone,  it  is  of  great  value. 

Two  operations  are  spoken  of — internal  and  external  pos- 
terior linear  proctotomy.  The  internal  consists  simply  of  a 
division  of  the  stricture  tissue  alone  by  an  incision  in  the 
median  line  behind;  the  cut  being  deep  enough  to  completely 
divide  all  of  the  fibrous  tissues.  The  external  operation  does 
this  and  more,  inasmuch  as  it  divides  not  only  the  stricture 
but  also  all  of  the  tissue  between  it  and  the  anus,  with  the 
sphincters. 

The  internal  incision  alone  is  a  very  dangerous  one.  It 
is  often  asked  why,  after  dividing  the  constriction,  go  on  and 
divide  healthy  tissue  below  it,  including  the  sphincters  ?  Simply 
for  drainage.     The  most  dangerous  incisions  in  the  surgery 


1 6  Stricture  of  the  Rectum. 

of  the  rectum  are  those  made  into  and  through  the  wall  of  the 
bowel  which  are  not  continued  to  the  surface — dangerous  both 
from  hemorrhage  and  sepsis.  In  the  only  case  in  which  I 
ever  performed  this  partial  incision  it  was  followed  by  a  dan- 
gerous pelvic  inflammation. 

The  external  operation,  on  the  other  hand,  provides  for  the 
control  of  hemorrhage  and  for  drainage  in  the  most  perfect 
way,  and  is  therefore  much  safer  though  more  extensive. 

The  originators  of  this  operation  employed  either  the  Paque- 
lin  cautery  knife  or  the  chain  ecraseur  for  the  incision,  both 
of  them  being  bloodless;  and  in  my  own  first  cases  I  used  the 
cautery.  But  the  bleeding  with  the  external  operation  is  not 
a  matter  to  be  feared,  being  easily  controlled  by  packing  the 
incision  with  charpie,  and  I  now  use  a  straight,  blunt-pointed 
bistoury  passed  into  the  bowel  and  through  the  stricture  on 
the  left  index  finger  as  a  guide.  Care  should  be  taken  to  have 
the  incision  reach  well  above  and  well  through  all  the  stric- 
ture tissue,  and  to  be  as  nearly  as  possible  in  the  median  line 
behind. 

The  danger  of  subsequent  incontinence  from  this  incision, 
if  the  sphincters  are  in  good  condition  when  it  is  made,  is  not 
very  g'reat;  but  the  wound  at  the  anus  generally  takes  many 
weeks  to  heal  and  this  is  a  great  objection  to  it.  There  are 
two  ways  of  avoiding  this.  One  suggested  and  practised  with 
good  result  by  Weir  is  to  confine  the  incision  to  the  stricture, 
leaving  the  anus  intact;  and  to  drain  this  incision  by  a  tube 
brought  out  through  the  skin  at  the  tip  of  the  coccyx.  This 
I  have  tried  in  several  cases  with  the  result  of  saving  much 
time.  The  tube  should  be  left  in  till  all  danger  of  periproctitis 
has  passed.  If  there  be  no  rise  of  temperature  by  the  fourth 
day  it  may  be  safely  removed,  and  the  wound  caused  by  it 
will  generally  heal  promptly. 

Another  method  I  have  sometimes  used  is  to  divide  the 
sphincters  and  then  employ  three  or  four  deep  provisional 
wire  sutures  between  the  anus  and  the  stricture,  leaving  them 
loose  and  stuffing  the  incision  with  charpie.  When  all  danger 
is  passed  and  granulation  is  well  under  way  the  opposing  sur- 
faces are  scraped  and  the  sutures  tightened.  This  may  be 
done  at  about  the  end  of  the  first  week,  and  as  more  or  less 
firm  union  is  pretty  sure  to  result  considerable  time  is  saved. 

The  one  great  danger  of  this  operation  is  septic  periprocti- 


Stricture  of  the  Rectum.  iy 

tis,  and  with  proper  precautions  as  to  antisepsis  and  drainage 
this  may  generally  be  avoided.  The  danger  of  primary  hem- 
orrhage is  not  great.  No  large  vessels  are  cut  and  all  bleed- 
ing is  within  easy  reach.  It  can  seldom  be  necessary  to  tie 
any  vessel  as  the  wound  can  so  readily  be  tightly  packed  with 
charpie.  Secondary  hamorrhage  I  have  seen  once  in  a  case 
of  very  extensive  cancer  divided  with  the  cautery. 

The  after-treatment  consists  only  in  the  use  of  the  bougie, 
commenced  as  soon  as  the  incision  has  begun  to  fairly  close 
up,  that  is  to  say,  after  three  or  four  weeks,  and  followed 
steadily  and  gently  as  already  indicated.  The  bougie  should 
be  used  for  three  or  four  hours  each  day,  or,  as  is  my  favorite 
practice,  introduced  when  the  patient  goes  to  bed  and  left  in 
all  night. 

In  the  great  majority  of  cases  the  short  instrument  will 
reach  above  the  disease,  and  after  one  or  two  trials  its  use 
may  be  left  to  the  patient.  If  pain  is  complained  of  it  is  a  sure 
indication  that  the  instrument  is  too  large  and  is  doing  harm. 

My  own  experience  with  this  method  is  given  at  the  end  of 
this  article.  Only  three  of  the  cases  were  malignant,  and 
these  three  have  given  me  no  encouragement  to  continue  its 
use — in  fact  my  old  antipathy  to  colotomy  is  the  only  reason 
for  ever  having  employed  it  in  malignant  stricture.  The  first 
case  of  malignant  disease  was  the  one  in  which  severe  and 
almost  fatal  secondary  hemorrhage  occurred  on  the  separa- 
tion of  the  sloughs  made  by  the  cautery.  The  patient  was  a 
middle-aged  woman  with  extensive  cancerous  deposit  and  yet 
in  good  condition.  The  disease  seemed  low  down  and  the  rec- 
tum was  nearly  occluded.  After  cutting  through  the  first 
stricture,  a  large  ulcerated  cavity  was  opened  up,  and  above 
this  was  a  second  stricture,  also  so  tight  that  the  opening 
could  hardly  be  discovered.  This  I  also  divided  with  great 
difficulty  and  constant  fear  of  the  peritoneum.  The  operation 
was  attended  by  a  good  deal  of  shock  and  the  patient  lived 
only  a  few  months.  From  her  good  general  condition  I  am 
satisfied  she  might  have  lived  two  or  three  years  with  a 
colotomy. 

The  second  case  of  cancer  was  in  a  young  man  also  with 
extensive  disease.  He  died  on  the  tenth  day,  apparently  from 
exhaustion,  mixed  with  some  anomalous  symptoms  of  septic 
peritonitis. 

VII— 2 


1 8  Stricture  of  the  Rectum. 

The  third  case — in  a  young  woman — was  fatal  in  eight  hours. 
The  disease  was  not  as  extensive  as  in  either  of  the  other  two, 
but  the  patient  was  exhausted  by  chronic  intestinal  obstruc- 
tion, and  sank  quickly  from  the  shock  of  the  operation.  She 
might  have  done  the  same  from  a  colotomy,  but  both  of  the 
others  would  probably  have  done  much  better  after  colotomy 
than  proctotomy. 

Neither  theoretically  nor  from  my  own  experience  can  I 
recommend  this  operation  in  malignant  disease.  The  danger 
of  it  is  certainly  as  great  as  that  of  a  colotomy,  and  nothing 
more  than  temporary  slight  benefit  can  be  hoped  for,  as  in  the 
nature  of  the  case  subsequent  dilatation  can  do  little  good. 

While  proctotomy  has  been  thus  unsatisfactory  in  malig- 
nant disease,  exactly  the  opposite  has  been  the  case  in  all  of 
the  benign  strictures,  and  here  I  have  never  had  occasion  to 
regret  its  performance.  For  all  cases  of  non-malignant  stric- 
ture which  are  not  so  far  beyond  the  reach  of  local  treatment 
that  colotomy  is  indicated  from  the  first,  the  choice  must  lie 
between  this  plan  of  treatment  and  complete  excision.  I  have 
within  a  few  weeks  performed  colotomy  on  a  patient  for  whom 
I  did  proctotomy  nine  years  ago,  and  who  for  five  years  after 
the  operation  was  in  a  greatly  improved  condition,  though  at 
that  time  most  men,  I  think,  would  have  considered  her  beyond 
hope  of  relief  from  anything  except  a  colotomy,  so  grievous 
was  her  condition:  she,  however,  gained  health  and  strength 
and  was  able  to  keep  the  stricture  well  under  control  till  about 
two  years  ago,  when  a  large  pelvic  abscess  formed  on  the  left 
side,  nearly  occluding  the  gut  above  the  original  stricture,  and 
discharging  large  quantities  of  pus  into  the  rectum.  For  this 
second  condition,  together  with  the  old  stricture,  I  did  the 
colotomy,  as  the  combination  was  rapidly  exhausting  her. 

Although  there  had  been  some  recontraction,  there  had 
been  no  increase  in  the  amount  of  fibrous  tissue,  and  no  re- 
turn of  the  ulceration  which  had  been  cured  by  the  operation 
of  nine  years  before. 

Other  cases  I  have  now  under  observation  in  which  the 
patients  have  been  so  greatly  improved  that  they  consider 
themselves  almost  entirely  cured,  and  can  only  be  induced  to 
use  the  bougie  at  long  intervals — cases  in  which  all  straining, 
tenesmus,  and  purulent  discharge  have  ceased,  and  in  which 
the  patients  have  one   natural  painless  passage  daily.     As 


Stricture  of  the  Rectum.  19 

long-  as  these  patients  can  be  made  to  care  for  themselves  and 
to  continue  the  use  of  the  bougie  with  regularity  they  are 
perfectly  comfortable,  but  the  neglect  of  the  bougie  has  in 
my  experience  invariably  been  followed  by  recontraction. 

In  a  general  way  it  may  be  said  of  this  plan  of  treatment 
that  in  selected  cases  of  non-malignant  disease— those  in  which 
the  ulceration  and  contraction  are  of  limited  area  and  do  not 
involve  too  great  an  extent  of  the  gut  in  length,  though  per- 
haps almost  completely  occluding  it— it  is  to  be  preferred  over 
all  others.  In  them  it  is  a  satisfactory  substitute  for  colotomy 
or  exsection,  and  in  some  it  will  effect  as  near  a  cure  as  is  ever 
gained  in  this  disease. 

Partial  Destruction.    Electrolysis.    Baclage. 

The  consideration  of  these  things  need  detain  us  but  a  mo- 
ment. In  benign  strictures  all  that  they  can  accomplish  can 
be  done  better  by  linear  proctotomy,  and  in  malignant  disease 
they  are  contra-indicated.  The  cauterization  or  scraping  of 
old  non-malignant  ulcers  of  the  rectum  has  its  undisputed 
value;  but  nothing  more  unsurgical  can  well  be  imagined 
than  the  application  of  nitric  acid  to  a  cancerous  rectum,  or 
the  attempt  at  partial  destruction  and  removal  by  any.  other 
means,  In  the  days  when  extirpation  was  considered  unjusti- 
fiable, and  colotomy  as  worse  than  death,  these  things  had 
their  place,  but  they  are  now  simply  examples  of  timid  and 
meddlesome  surgery. 

With  regard  to  electrolysis  we  occasionally  see  a  case  of 
"perfect  cure"  reported  by  this  means  in  some  journal,  but 
never  one  in  which  the  certainty  of  that  result  is  verified 
beyond  suspicion.  Electrolysis  reduced  to  fact  means  in  the 
treatment  of  stricture  of  the  rectum  either  simple  dilatation 
or  the  application  of  the  cautery.  The  olive-pointed  electrodes 
placed  against  a  stricture  and  gently  pressed  inward  for  ten 
or  fifteen  minutes  will  cause  exactly  the  same  amount  of  dila- 
tation and  absorption  whether  the  elaborate  battery  be  con- 
nected with  them  or  not;  and  when  we  come  to  cauterization 
the  battery  will  accomplish  no  more  and  no  less  than  any  other 
destructive  agent.  This  at  least  is  the  result  of  a  careful 
series  of  experiments  with  this  means  of  treatment  in  my  own 
practice— experiments  which,  after  two  years'  trial,  had  ac- 


20  Stricture  of  the  Rectum. 

complistied  nothing-  not  attainable  by  much  simpler  means. 
I  do  not  mean  to  say  that  with  a  current  of  sufficient  strength 
a  passage  cannot  be  made  through  a  cancerous  stricture,  be- 
cause this  is  exactly  what  can  be  done,  but  a  mild  current  has 
no  effect  and  a  strong  one  simply  cauterizes. 

Excision. 

With  regard  to  excision  there  are  two  questions  to  be  con- 
sidered: First,  the  class  of  cases  to  which  it  is  best  adapted; 
and,  second,  the  best  method  of  its  performance. 

Extirpation  of  the  rectum  has  until  recently  been  consid- 
ered as  indicated  only  in  malignant  disease,  but  of  the  pro- 
priety of  thus  limiting  the  scope  of  the  operation  I  am  be- 
ginning to  have  serious  doubts — doubts  which  will  be 
settled  not  alone  by  the  supposed  dangers  of  the  operation, 
but  also  by  the  comparative  comfort  of  the  patients  with 
extensive  benign  strictures  after  extirpation  and  after  the 
other  methods  of  treatment  at  our  disposal.  The  clanger 
of  extirpation  in  selected  cases  is  not,  to  my  mind,  so  much 
greater  than  that  of  proctotomy  that  I  should  hesitate  on  this 
account  alone  to  do  the  former  instead  of  the  latter,  were  I 
satisfied  that  by  it  the  patient  could  be  rendered  more  com- 
fortable, both  as  regards  faecal  incontinence  and  subsequent 
stricture  due  to  the  operation. 

My  personal  experience  with  extirpation  of  benign  stricture 
is  limited,  as  will  be  seen  by  the  table,  but  all  of  the  cases  have 
resulted  favorably  as  regards  sphincteric  power  and  the  ab- 
sence of  recontraction;  and  though  these  are  manifestly  not 
sufficient  to  generalize  upon,  they  are  enough  to  make  me 
anxious  to  try  the  treatment  further  in  selected  cases.  As  it 
appears  to  me  now,  it  is  a  possible  substitute  for  proctotomy 
and  dilatation  in  the  class  of  cases  to  which  these  are  best 
applicable,  rather  than  for  colotomy.  Were  the  disease  suffi- 
ciently extensive  to  make  colotomy  seem  necessary,  it  would 
probably  be  too  great  for  extirpation,  as  is  the  case  with 
malignant  stricture.  But  where  the  induration  is  great,  the 
stricture  close,  and  yet  so  much  of  the  gut  is  not  involved  in 
Length  that  a  complete  circular  resection  with  preservation  of 
the  sphincters  cannot  be  done,  I  am  not  sure  that  experience 
will  not  soon  teach  that  it  is  better  to  relieve  the  patient  of 


Stricture  of  the  Rectum.  21 

his  disease  at  one  stroke  than  to  trust  to  making*  him  com- 
fortable by  proctotomy  and  subsequent  dilatation.  It  is  the 
choice  between  cure  and  palliation,  and  it  must  be  decided  by 
the  condition  in  which  the  rectum  can  be  left  as  regards 
stricture  and  incontinence  after  extirpation. 

Extirpation  for  cancerous  disease  will  hardly  again  in  the 
future  be  abandoned,  as  it  was  in  the  past,  as  unjustifiable. 
All  that  now  remains  for  it  is  to  decide  the  proper  limits  of 
its  applicability  and  if  possible  improve  upon  its  technique. 
Even  were  it  to  be  decided  that  in  a  majority  of  cases  an  early 
colotomy  gave  longer  life  than  extirpation,  we  should  probably 
all  go  on  doing  the  latter  operation;  for  a  possible  cure  would 
more  than  counterbalance  any  additional  safet}r  of  colotomy 
with  its  certain  death  after  a  time  but  short  at  the  best. 

The  limits  of  •  extirpation  in  cancer  have  not  yet  been  de- 
termined. On  the  one  hand  are  the  German  surgeons  tend- 
ing to  the  most  radical  operations  and  removing  the  en- 
tire rectum  up  to  the  sigmoid  flexure  with  at  least  temporary 
success.  Opposed  to  these  are  the  English  specialists  advo- 
cating more  conservative  practice,  and  tending  to  restrict  the 
operation  to  disease  of  comparatively  limited  extent;  while 
in  America  we  are  trying  both  plans,  doing  at  times  fully 
as  radical  operations  as  the  Germans,  and  waiting  for  the 
results  of  clinical  experience. 

Since  Kraske  has  shown  us  a  new  way  of  attacking  the 
rectum,  the  mere  question  of  the  length  of  gut  to  be  removed 
has  lost  some  of  its  importance;  and  the  question  is  now  not 
whether  the  disease  reaches  above  a  point  which  can  easily 
be  attained  by  dividing  the  anus  and  rectum  down  to  the  tip 
of  the  coccyx;  but  whether,  when  the  disease  is  much  more 
extensive  than  this,  its  removal,  which  is  surgically  possible,  is 
attended  by  good  results  in  prolonging  life.  No  surgeon 
would  to-day  hesitate  to  remove  eight  inches  of  rectum  instead 
of  three  were  he  convinced  that  in  such  extensive  disease  all 
involved  lymphatics  could  also  be  removed,  and  that  the  chance 
of  immediate  recurrence  Avas  no  greater  in  the  major  than  in 
the  minor  operation. 

One  rule  may  be  considered  as  established — the  disease 
should  not  be  attacked  with  the  knife  unless  there  is  reason- 
able certainty  that  it  can  all  be  removed,  and  that  that  the 
lymphatics  have  not  to  any  extent  become  involved.     A  chain 


22  Strictu?'e  of  the  Rectum. 

of  lymphatics  in  the  hollow  of  the  sacrum  may  sometimes  he 
extirpated  if  they  are  involved  at  the  time  of  the  operation, 
hut  the  chance  of  removing-  them  all  under  such  circumstances 
is  not  good,  and  a  speedy  return  may  he  anticipated.  A  point 
has  also  recently  heen  made  by  Cripps  that  the  operation  is 
of  doubtful  propriety  when  the  disease  involves  the  upper  part 
of  the  recto-vaginal  septum  where  it  is  covered  by  peritoneum ; 
for  the  reason  that  the  latter,  if  involved,  will  speedily  cause  a 
recurrence.  If  this  point  be  well  taken,  it  will  greatly  limit 
the  field  of  the  operation,  and  reduce  it  to  what  was  its  limit 
before  Kraske's  method  was  discovered,  that  is,  to  disease  low 
down  in  the  rectum  and  freely  movable  on  the  adjacent  struc- 
tures. The  fear  of  wounding  the  peritoneum  itself  has  long 
since  passed  away,  the  mere  opening  of  that  cavity  having 
little  effect  upon  the  mortality  of  the  operation. 

In  deciding  the  question  as  to  the  immediate  mortality  of 
exsection,  a  large  number  of  cases  by  an  individual  operator 
is  much  more  valuable  than  an  equal  number  of  scattered 
cases  by  various  surgeons ;  for  the  success  or  fatality  of  this 
operation  may  easily  depend  upon  individual  skill.  Other 
things  being  equal,  the  man  who  has  operated  most  frequently 
will  get  the  best  results. 

Before  undertaking  an  extirpation,  the  patient  should  be 
carefully  prepared  for  operation.  Rest  in  bed  for  a  few  days 
to  accustom  him  to  the  enforced  quiet  to  follow  is  an  excellent 
idea.  The  bowels  should  be  thoroughly  unloaded,  beginning 
with  something  to  act  upon  the  liver  at  least  three  da}^  before 
the  operation,  and  following  this  with  small  doses  of  salines 
on  the  succeeding  days.  Two  hours  before  operation  a  final 
enema  of  water  should  be  administered  and  the  ano-perineal 
region,  buttocks,  and  sacral  region  thoroughly  disinfected,  first 
by  shaving  and  then  by  washing  with  bichloride  1  to  2,000. 

Although  this  usual  and  advantageous  preparation  of  the 
patient  is  always  best  when  possible,  in  some  cases  of  tight 
stricture  and  faecal  impaction  a  course  of  purgation  may  end 
fatally  from  a  weakened  and  ulcerated  bowel,  or  may  fail  en- 
tirely to  bring  away  anything  but  fluid.  Where  the  passage 
is  comparatively  free,  my  own  rule  is  to  clear  out  the  bowels, 
but  in  cases  of  tight  stricture  with  chronic  obstruction  the 
danger  of  this  course  is  greater  than  that  of  operation  in  the 
patient's  usual  condition. 


Stricture  of  the  Rectum. 


23 


Either  ether  or  chlorofor  mmay  he  used  as  an  anaesthetic, 
depending-  upon  the  condition  of  the  patient  or  the  preferences 
of  the  operator;  and  the  patient  should  be  held  in  the  litho- 
tomj^  position  by  Clover's  clutch,  provided  the  incision  is  to  be 
in  the  perineum  (Fig1.  5). 

The  technique  .of  the  operation  will  vary  with  the  amount 
of  disease  to  be  removed.  Let  us  take  first  a  case  of  stricture 
beginning  an  inch  or  so  above  the  sphincters  and  extending 
say  three  or  four  inches  up  the  bowel,  in  which  it  is  necessary 
to  remove  a  complete  cylinder  of  the  rectum.     One  great  ob- 


Fig.  5.— Clover's  Crutch  (Peter's  Modification). 


ject  will  be  to  preserve  the  anus  and  sphincters  intact,  and 
this  may  easily  be  done  by  the  following  method. 

A  blunt-pointed  straight  bistoury  is  passed  into  the  rec- 
tum and  the  anus  is  divided  in  the  median  line  behind  as  far 
up  as  is  possible  without  encroaching  upon  the  disease.  For 
safety  half  an  inch  of  healthy  mucous  membrane  should  be 
removed  with  the  affected  part  both  above  and  below  the 
edge  of  the  cancer,  and  the  rectum  by  this  first  dorsal  incision 
through  the  sphincters  should  be  divided  up  to  that  limit. 

The  blunt-pointed  bistoury  is  of  no  further  use  and  a  long, 
strong,  sharp-pointed  scalpel  is  substituted.     This  is  entered 


24 


Stricture  of  the  Rectum. 


in  the  wound  already  made  and  passed  along-  behind  the  rec- 
tum till  its  point  has  passed  the  upper  limit  of  the  growth  as 
indicated  by  the  finger  of  the  left  hand  in  the  gut.  All  of  the 
tissue  behind  the  gut  with  the  skin  is  then  divided  in  the 
median  line  by  a  single  sweep  of  the  knife.  The  second  in- 
cision simply  deepens  the  first  and  carries  it  to  a  point  above 
the  disease;   though  the  first  divided  bowel  and  the  second 


does  not  touch  bowel  but  divides  the  tissue  behind  it.  The 
object  is  to  dissect  out  as  rapidly  as  possible  the  diseased  por- 
tion of  gut  as  a  cylinder  and  without  dividing  it. 

The  second  knife  is  now  abandoned  and  the  operation  is 
completed  with  the  scissors  shown  in  the  cut,  Fig.  6,  the  dorsal 
incision  being  tightly  packed  with  large  firm  sponges  and  the 
edges  of  the  wound  held  open  by  the  retractors  shown,  Fig.  7. 

With  the  left  index  finger  in  the  diseased  cylinder  for  a 
guide,  the  right  side  of  the  affected  gut  is  freed  from  its  at- 


FrG.  7.— Retractor. 


tachments  in  the  ischio-rectal  fossa  by  a  few  bold  cuts  with 
the  scissors  till  the  attachment  of  the  levator  ani  on  that  side 
is  reached  and  cut  through,  and  the  same  thing  is  done  on  the 
left  side  as  rapidly  as  possible.  If  the  operator  be  ambidex- 
trous the  hands  may  be  changed,  otherwise  the  cutting  on  the 
left  side  may  easily  be  accomplished  by  crossing  hands.  The 
skill  and  boldness  of  the  operator  is  shown  at  this  part  of  the 


Stricture  of '  the  Rectum. 


25 


operation  better  than  at  any  other.  The  inexperienced  tries 
to  make  a  careful  dissection  and  stops  for  hemorrhage,  while 
he  who  has  operated  before,  completes  this  stage  of  the  work 
with  a  few  bold  strokes  and  leaves  the  bleeding  to  his  assist- 
ant with  his  sponges  and  pressure. 

The  next  stage  in  the  operation  is  the  separation  of  the 
rectum  from  its  attachments  in  front  to  the  prostate  in  the 
male  and  the  vagina  in  the  female.  In  the  male  a  sound  in 
the  bladder  is  of  great  assistance,  and  the  separation  in  either 
sex  can  best  be  accomplished  with  the  handle  of  a  scalpel  or 
the  closed  blades  of  the  scissors,  unless  the  disease  has  invaded 
adjacent  parts,  when  slower  work  with  the  knife  may  be  nec- 
essary. 

In  this  operation  two  or  three  pairs  of  long  forceps  such 
as  are  shown  in  Fig.  8  will  be  found  of  great  assistance.  In 
one  of  my  own  cases  the  stricture  was  so  tight  that  the  index 


Fig.  8. — Long  Forceps  for  Incision. 


finger  could  not  be  passed  through  it  as  a  guide,  and  the  whole 
mass  was  seized  with  such  a  pair  of  forceps  while  the  dissec- 
tion was  carried  out  around  it. 

When  the  separation  has  been  properly  completed  on  all 
sides,  the  diseased  cylinder  will  be  found  to  be  perfectly  free 
and  can  be  pulled  down  and  cut  off  above  the  disease  with 
ease.  If  it  does  not  come  down  to  the  surface  easily,  the  point 
of  attachment  will  usually  be  found  at  the  insertion  of  some 
fibres  of  the  levator.  The  healthy  rectum  is  then  seized  with 
a  pair  of  long  forceps  to  prevent  its  retraction,  and  the  gut  is 
cut  across  with  the  scissors  about  half  an  inch  above  the  dis- 
ease ;  the  wound  is  tightly  packed  with  sponges  and  the  speci- 
men examined  carefulty  to  see  that  the  operation  has  been 
complete  and  that  no  cancerous  tissue  has  been  left. 

Up  to  this  point  no  bleeding  vessels  have  been  tied.  Ex- 
cepting the  first  dorsal  incision  it  is  useless  to  tie  them  till  the 
operation  is  completed,  as  they  all  come  from  above  and  the 
same  vessel  may  be  cut  across  and  require  the  ligature  several 


26  Stricture  of  the  Rectum. 

times.  It  is  much  better  to  trust  to  sponges  to  control  the 
bleeding-  till  the  extirpation  is  completed,  when  it  will  be  found 
that  only  a  few  ounces  of  blood  have  been  lost  and  not  more 
than  half  a  dozen  ligatures  are  required.  I  have  completed 
the  operation  with  only  two  ligatures. 

The  operation  from  the  time  of  the  first  incision  to  the  sec- 
tion of  the  bowel  above  the  disease  and  the  securing  of  all 
bleeding  points  should  not  consume  in  a  simple  case  more 
than  ten  minutes,  and  in  a  difficult  one  five  more  may  be  al- 
lowed for  separating  the  gut  from  its  anterior  attachments. 
It  will  be  seen  at  once  that  this  is  a  very  different  matter 
from  the  old  and  tedious  dissection  from  below  upward,  made 
with  successive  strokes  of  the  knife  and  requiring  hours  for 
the  application  of  ligatures,  each  vessel  being  cut  and  tied  again 
and  again  as  the  dissection  was  carried  upward  into  the  pelvis. 

The  subsequent  treatment  of  the  wound  thus  made  is  a 
matter  of  individual  preference. 

The  German  surgeons  generally  try  to  get  primary  union 
by  drawing  the  end  of  the  rectum  down  to  the  skin,  attaching 
it  by  a  row  of  sutures;  closing  as  much  as  possible  of  the  dor- 
sal incision  and  introducing  drainage  tubes. 

The  English  operators  (Cripps,  Allingham)  prefer  the 
greater  safety  of  an  open  wound,  stitch  the  gut  lightly  to  the 
skin,  introduce  drainage  tubes,  and  leave  the  wound  to  close 
by  granulation. 

In  my  own  earlier  cases  I  leaned  to  the  latter  method,  but 
having  had  no  bad  results  from  this  cause  I  have  in  each  suc- 
cessive case  tried  a  little  more  definitely  for  as  much  primary 
union  as  possible.  Much  time  is  saved  if  any  considerable 
part  of  the  incision  can  be  closed  by  first  intention,  and  there 
is  less  cicatricial  stricture  to  be  dilated  subsequently.  For 
this  reason  I  now  draw  the  end  of  the  gut  well  down,  fasten 
it  accurately  to  the  sphincters  in  front  and  at  the  sides,  pass 
a  drainage  tube  into  the  dorsal  incision  on  each  side  of  the 
gut  at  the  level  of  the  tip  of  the  coccyx,  and  introduce  deep 
silver  sutures  to  close  the  dorsal  incision  but  leave  them  loose. 
The  dorsal  incision  is  then  packed  with  iodoform  gauze.  After 
a  week,  if  all  has  gone  well,  the  tubes  may  be  removed,  the 
granulating  surfaces  of  the  dorsal  incision  scraped,  and  the 
silver  sutures  drawn  tight.  In  this  way  I  have  saved  much 
time  without  increasing  the  danger  of  periproctitis. 


Stricture  of  the  Rectum. 


27 


It  is  needless  to  say  that  at  every  step  in  this  operation 
the  most  complete  antisepsis  should  be  observed;  for  these 
cases  die,  when  they  do  die,  of  septic  periproctitis  oftener  than 
from  all  other  causes  combined.  After  the  operation  a  large 
and  perfect  absorbent  antiseptic  dressing1  should  be  employed, 
and  opium  should  be  given  freely  with  absolute  milk  diet  to 
confine  the  bowels  for  at  least  a  week.  Should  the  bowels 
move  involuntarily,  so  as  to  make  the  removal  of  the  first 
dressing  necessary,  or  should  there  be  any  rise  of  tempera- 
ture, the  wound  may  subsequently  be  treated  as  an  open  one 
and  reliance  be  placed  upon  thorough  irrigation.    Should  there 


Fig.  9  (Allingham). 


be  chill  and  an  alarming  rise  of  temperature,  all  sutures  should 
be  cut,  the  parts  opened  widely  up,  and  irrigation  with  weak 
bichloride  or  salicylic  acid  solutions  used  to  reduce  the  tem- 
perature; but  this  accident  has  never  happened  to  me. 

The  operation  thus  described  may  be  modified  in  many 
ways  according  to  the  nature  of  the  case. 

The  disease  may  involve  the  sphincters,  in  which  case  the 
deep  dorsal  incision  should  be  made  by  entering  the  bistoury 
behind  the  anus  through  the  skin  between  it  and  the  coccyx. 
Two  semicircular  incisions  should  then  be  made  through  the 
skin  which  together  surround  the  anus,  meeting  in  the  peri- 
neum in  front  and  in  the  dorsal  cut  behind  (Figs.  9  and  10). 
The  diseased  gut  and  sphincters  should  then  be  dissected  out 
as  a  cylinder  as  in  the  former  case.     The  operation  is  no  more 


28 


Stricture  of  the  Rectum. 


serious  than  the  other,  but  there  will  of  course  be  no  sphino 
teric  power  after  the  patient  recovers,  though  there  may  not 
be  any  trouble  from  incontinence. 

The  disease  in  other  cases  may  consist  in  a  circumscribed 
nodule  in  some  part  of  the  rectal  pouch  which  must  be  re- 
moved without  any  attempt  to  remove  the  gut  as  a  Cylinder, 
This  operation  is  apt  to  be  more  difficult  and  bloody  than  the 
method  already  described.  The  dorsal  incision  which  is  the 
key  to  all  these  operations  should  be  made  as  in  the  first 
case.  The  mass  must  then  be  attacked  boldly  and  extirpated 
as  quickly  as  possible.  ;  There  will  be  no  time  for  careful  dis- 
section in  such  cases.     It  is  better  to  remove  too  much  than 


Fig.  10  (Allingham). 


jboo  little,  and  bleeding  must  be  disregarded  till  the  diseased 
mass  is  removed  by  a  few  bold  strokes  with  knife  or  scissors. 

In  my  first  operation  of  this  sort — a  case  of  ulcerated  epi- 
thelioma at  the  level  of  the  prostate  on  the  anterior  wall  of 
the  gut — I  encountered  a  bleeding  which  was  very  startling. 
All  went  well  till  after  the  dorsal  incision  was  made,  and  I  at- 
tempted to  circumscribe  the  disease  with  a  sort  of  limiting 
useless  incision  not  much  deeper  than  the  mucous  membrane, 
which  was  intended  as  a  guide  for  the  amount  of  tissue  sub- 
sequently to  be  removed  by  a  careful  dissection.  Before  this 
plan  of  future  work  could  even  be  mapped  out,  the  bleeding 
was  so  profuse  as  to  render  its  instant  control  absolutely 
necessary;  and  never  before  or  since  have  I  abandoned  an 
attempt  at  graceful  surgery  and  simply  extirpated  a  mass  of 


Stricture  of  the  Rectum.  29 

cancerous  tissue  with  the  same  celerity.  The  moment  the 
disease  was  out  the  bleeding"  was  completely  under  the  con- 
trol of  pressure  by  a  few  sponges.  I  mention  the  case  simply 
to  illustrate  as  forcibly  as  possible  that  the  secret  of  success 
in  extirpation  of  the  rectum  is  to  remove  the  diseased  mass 
as  speedily  as  is  possible,  and  to  control  the  bleeding  by  pres- 
sure during  the  operation  and  afterward  till  ligatures  can  be 
applied.  In  all  my  experience  in  operations  of  every  sort 
upon  the  rectum  I  have  never  seen  a  case  of  hemorrhage 
which  could  not  be  effectually  controlled  by  direct  pressure 
properly  applied. 

There  is  one  after-consequence  of  these  operations  which 
must  be  carefully  guarded  against  in  the  treatment,  and  that 
is  cicatricial  contraction.  Of  course  the  substitution  of  a 
cicatricial  contraction  for  a  malignant  occlusion  is  a  great 
gain;  but  even  the  cicatricial  contraction  may  be  in  great 
measure  avoided  by  proper  care.  As  soon  as  such  contrac- 
tion begins  to  manifest  itself,  say  in  three  or  four  weeks  after 
the  operation,  the  patient  must  be  instructed  to  use  the  short 
bougie  already  described  in  speaking  of  dilatation.  One  of 
ample  size  (Nos.  8  or  9)  should  be  chosen  and  introduced  daily, 
being  left  in  for  several  hours.  I  much  prefer  having  the 
patient  introduce  them  on  going  to  bed  and  leaving  them  in 
all  night.  Generally  they  will  cause  no  inconvenience,  and 
the  patient  will  not  be  conscious  of  their  presence.  By  this 
means  contraction  may  either  be  entirely  prevented,  or  may 
be  so  limited  as  to  do  no  harm. 

Kraske's  Operation. 

The  various  operations  which  are  included  under  this  gen- 
eral hea  d  are  all  designed  to  effect  an  entrance  into  the  cavity 
of  the  pelvis  by  an  incision  at  the  left  side  of  the  sacrum.  Bjr 
such  an  incision  the  entire  rectum  may  be  removed  without 
interference  with  the  sphincters,  and  many  of  the  more  diffi- 
cult operations  upon  the  female  genital  organs  may  be  per- 
formed in  addition.  The  operation  upon  the  rectum  may  be 
either  of  the  nature  of  an  amputation  or  a  resection. 

There  have  been  several  modifications  of  Kraske's  original 
method,  but  all  of  them  may  be  reduced  to  two  general  plans. 
The  first  is  merely  an  enlargement  of  the  incision  already  de- 


30  Strichire  of  the  Rectum. 

scribed  for  exsection,  upward  through  the  left  sacro-sciatic 
ligament,  combined  with  amputation  of  the  coccyx  and  the 
removal  of  the  end  and  left  border  of  the  sacrum.  The  other 
consists  in  approaching  the  disease  from  behind  instead  of 
below.  The  incision  in  this  case  is  made  from  the  middle  of 
the  sacrum  to  the  tip  of  the  coccyx  reaching  down  to  bone. 
The  soft  parts  on  the  left  side  of  the  incision  are  then  detached, 
the  left  sacral  and  coccygeal  ligaments  are  divided  as  high  up 
as  the  third  sacral  foramen,  and  the  coccyx  is  removed.  If 
still  more  room  be  necessary,  the  sacrum  may  be  chiselled 
away  on  a  line  from  the  third  foramen  down  to  the.  tip,  and 
the  lower  sacral  vertebrae  may  be  removed.  The  first  incision 
is  best  adapted  to  cases  involving  the  anus  where  the  whole 
rectum  has  to  be  amputated;  the  second  to  actual  resections 
of  a  part  of  the  rectum  with  union  of  the  divided  ends.  In 
this  operation  the  peritoneum  is  of  necessity  opened,  and  it 
may  be  left  so  after  the  upper  end  of  the  gut  has  been 
drawn  down,  a  drainage  tube  being  inserted  into  the  perito- 
neal cavity  and  the  wound  packed  with  iodoform  gauze;  or 
the  cut  edge  of  the  peritoneum  may  be  stitched  to  the  serous 
surface  of  the  sigmoid  flexure  as  Schede  has  proposed.  The 
divided  ends  of  the  gut  are  united  more  or  less  closely  by  su- 
tures, and  where  the  whole  of  the  anus  has  been  removed  the 
end  of  the  gut  has  in  some  cases  been  brought  to  the  surface 
at  the  upper  limit  of  the  wound,  and  an  artificial  anus  estab- 
lished in  the  sacral  region. 

This  is  not  a  place  to  go  into  an  elaborate  study  of  the 
statistics  of  this  operation,  nor,  as  yet,  are  these  statistics  of 
great  value.  Suffice  it  to  say  that  they  are  steadily  improv- 
ing, but  are  still  much  worse  than  those  of  the  operation  pre- 
viously described,  as  would  naturally  be  expected.  What  has 
been  thoroughly  established  is  that  the  entire  rectum  and 
anus  may  be  removed  by  a  rapid  operator  by  this  method  in 
about  twenty  minutes,  and  that  a  fair  proportion  of  the  cases 
recover  with  more  or  less  permanent  disability  in  the  way  of 
cicatricial  contraction,  incontinence,  and  fsecal  fistula  in  the 
sacral  region.  The  operation  has  certainly  earned  for  itself  a 
permanent  place  in  the  surgery  of  the  rectum;  and  the  length 
of  life  after  it  when  patients  recover  seems  fully  as  great  as 
after  the  lighter  operation.  In  none  of  my  own  cases  has  it 
seemed  applicable  for  the  reason  that  in  all  in  which  such  an 


Stricture  of  the  Rectum.  31 

incision  would  have  been  necessary  to  remove  the  disease,  the 
adjacent  structures  have  been  so  much  involved  that  I  pre- 
ferred colotomy. 

Extirpation  of  eight  inches  of  the  rectum  where  the  disease 
involves  only  the  rectum  may  be  proper;  but  extirpation  of 
rectum,  prostate,  and  cancerous  peritoneum  is  a  different 
matter,  and  is  an  operation  which  I  have  never  yet  been  ready 
to  attempt.  I  have,  however,  practised  the  dorsal  incision  in 
several  cases  for  the  sake  of  better  attacking-  deep  recto- 
vaginal and  other  fistula?  and  have  been  surprised  at  the  ease 
with  which  the  disease  could  be  approached. 

Colotomy 

It  will  be  seen  at  once  from  what  has  preceded  that  the 
field  of  this  operation  has  been  greatly  encroached  upon  by 
the  operation  of  excision;  and  yet,  in  other  directions,  it  has 
been  increased.  It  is  easy  to  state  in  a  general  way  the  class 
of  cases  to  which  colotomy  is  best  adapted.  They  are:  First, 
the  old  and  incurable  cases  of  non-malignant  ulceration,  stric- 
ture, and  fistula?  which  are  threatening  life  either  by  exhaus- 
tion or  obstruction.  Second,  the  cases  of  obstruction  from 
pressure  outside  of  the  bowel,  as  in  cancer  of  the  pelvis,  or  old 
pelvic  inflammation,  and  cases  of  intestino-vesical  fistula. 
Third,  the  cases  of  cancer  of  the  rectum  in  which  excision  is 
for  any  reason  contra-indicated. 

My  own  series  of  inguinal  colotomies  illustrate  nearly  all 
of  the  different  classes  of  cases  calling  for  the  operation,  in- 
cluding as  they  do  cases  of  cancer  with  vesico-intestinal  fistula ; 
extensive  non-malignant  ulceration  and  stricture;  acute  ob- 
struction by  pressure;  and  the  ordinary  cases  of  malignant 
stricture.  Nearly  all  have  been  satisfactory  in  prolonging 
life  and  relieving  pain.  In  one  I  operated  upon  a  gentleman 
whose  rectum  and  pelvis  were  filled  up  with  cancer,  on  his 
eightieth  birthday.  He  had  been  told  a  year  before  that  a 
colotomy  would  "  eventually "  be  necessary,  and  when  I  was 
called  upon  to  do  the  operation  he  was  very  near  the  end. 
After  consultation  I  expressed  my  willingness  to  operate 
should  the  patient  and  family  physician  wish  it,  but  declined 
to  go  further  than  this.  I  did  operate,  the  patient  did  well 
till  the  bowel  was  finally  opened  on  the  third  clay  and  two 


32  Stricture  of  the  Rectum. 

large  faecal  passages  had  occurred,  and  then  he  sank  quickly 
and  died.  I  have  never  attributed  this  death  to  the  opera- 
tion. All  that  can  he  said  of  the  operation  is  that  it  failed  to 
prolong  life.  The  patient  was  liable  to  die  at  any  moment,  in 
fact  very  nearly  died  upon  the  table.  The  operation  was  done 
with  the  least  possible  shock  and  was  entirely  completed  in 
seventeen  minutes  from  the  time  of  the  incision,  and  yet  in 
spite  of  it  he  died.  The  attempt  to  prolong-  life  was  a  desper- 
ate one  and  it  failed,  but  there  was  no  proof  that  it  shortened 
it  by  a  single  hour. 

Another  of  my  cases  was  unsuccessful,  but  from  no  fault 
of  the  operation.  The  patient  was  over  sixty,  and  much  ex- 
hausted with  the  cancerous  disease.  When  the  abdomen  was 
opened  it  was  found  partially  filled  with  serum;  the  intestine 
was  greatly  congested,  and  the  entire  mesentery  was  infil- 
trated with  cancer.  There  wTere  no  distended  coils  of  gut, 
both  large  and  small  bowel  being  empty  and  contracted.  It 
was  with  great  difficulty  that  a  piece  of  the  sigmoid  flexure 
could  be  stitched  into  the  abdominal  incision  so  closely  was  it 
bound  down  by  cancerous  infiltration  of  the  mesentery,  and  a 
loop  of  small  intestine  which  also  appeared  in  the  wound  was 
only  a  trifle  more  movable.  The  large,  intestine  was  chosen 
and  with  difficulty  sutured,  the  muscular  layer  being  very 
friable.  The  patient  did  well  for  forty  hours,  when  severe 
vomiting  began  and  the  temperature  steadily  rose  to  105°  with 
signs  of  collapse.  The  wound  was  examined  and  found  in 
good  shape;  the  bowel  was  incised  but  there  was  no  escape  of 
gas  as  is  usual,  and  only  a  small  quantity  of  fasces  was  found 
by  introducing  the  finger  into  the  proximal  end.  Death  fol- 
lowed in  a  few  hours  with  all  the  symptoms  of  collapse,  and 
on  opening  the  abdomen  a  complete  obstruction  with  a  gan- 
grenous loop  was  found  in  the  large  intestine  at  the  splenic 
flexure.  The  obstruction  was  due  to  a  band  of  cancerous 
mesentery  which  had  caused  a  sharp  flexure  in  the  gut,  which 
flexure  was  completely  obstructed  by  a  small  scybalous  mass. 
Although  the  obstruction  had  been  fatal  in  less  than  twelve 
hours,  there  was  no  great  distention  of  the  large  intestine 
above  the  obstructed  point;  and  though  I  had  opened  the  gut 
as  soon  as  the  vomiting  began,  under  the  impression  that  the 
symptoms  might  be  due  to  the  complete  obstruction  caused 
by  the  operation,  the  failure  to  find  any  obstruction  at  the 


Stricture  of  the  Rectum.  33 

wound,  joined  to  the  fact  of  a  temperature  of  105°,  led  me  to 
suppose  the  patient  dying'  of  septic  peritonitis. 

A  second  opening"  of  the  abdomen  might  have  saved  the 
patient's  life  for  a  few  weeks,  but  the  sudden  and  complete 
collapse,  and  the  already  known  condition  of  the  abdominal 
contents,  seemed  to  contra-indicate  further  surgery. 

Such  cases  as  these  in  no  way  militate  against  the  general 
good  results  of  the  operation  we  are  considering. 

Regarding  colotomy  there  are  a  few  general  considerations 
to  which  it  may  be  well  to  caLll  attention. 

It  is  not  a  dangerous  operation  when  done  under  anything 
like  favorable  circumstances,  that  is,  before  the  sufferer  is  in 
the  last  stage  of  the  disease  and  exhausted  by  intestinal  ob- 
struction or  by  suffering.  Cripps  very  justly  calls  attention 
to  the  worthlessness  of  statistics  on  this  point  as  made  from  a 
large  number  of  separate  cases  by  individual  operators;  for 
the  mortality  of  the  operation,  as  with  extirpation,  must 
always  bear  a  very  close  relation  to  the  skill  and  experience 
of  the  operator,  and  unsuccessful  cases  do  not  find  their  way 
into  print.  For  himself  he  reports  forty-one  cases  with  one 
death. 

As  to  the  benefits  arising  from  the  operation,  too  much  can 
scarcely  be  said.  That  it  prolongs  life  by  the  relief  of  pain, 
the  prevention  of  obstruction,  and  retarding  the  growth  of 
cancerous  disease,  is  beyond  question.  That  it  substitutes  in 
many  cases  a  painless  death  for  one  of  great  agony  is  also  in- 
disputable. My  own  objections  to  the  operation  were  at  one 
time  deeply  rooted,  but  they  have  been  entirely  removed  by 
seeing  one  or  two  cases  in  which  stricture  had  been  left  to  its 
own  course  and  termination  in  complete  obstruction  and  rup- 
ture of  the  gut;  and  by  seeing  the  amount  of  relief  which  has 
followed  an  artificial  anus.  The  idea  that  it  is  as  well  to  let  a 
patient  die  as  to  subject  him  to  a  colotomy  has  no  supporters 
among  surgeons  who  have  had  any  experience  with  these 
cases.  Indeed  I  think  that  the  practitioner  who  to-day  sat 
by  and  allowed  a  patient  to  die  of  obstruction  because  of  any 
sentiment  against  this  procedure  would  hardly  be  held  blame- 
less. I  can  only  say  that,  after  trying  every  other  means  of 
treatment  and  being  obliged  to  admit  the  fruitlessness  of 
them  all,  I  have  come  with  most  others  to  admit  the  great 
benefits  of  colotomy,  and  have  never  performed  it  in  any  case 
VII— 3 


34  Stricture  of  the  Rectum. 

in  which  either  the  patient  or  myself  has  afterward  regretted 
it.  This  is  exceedingly  well  exemplified  in  one  of  my  patients 
upon  whom  I  did  the  operation  for  non-malignant  disease. 
The  rectum  has  so  far  healed  that  I  have  offered  to  close  the 
artificial  anus;  hut  she  will  not  consent.  The  memory  of  her 
old  sufferings  is  too  vivid  and  her  present  comfort  too  great. 

There  can  he  no  argument  in  favor  of  colotomy  so  strong 
as  a  single  experience  with  a  case  of  cancer  of  the  rectum  left 
to  its  own  course  and  termination  in  fatal  obstruction;  and  I 
think  that  no  matter  how  strong  one's  prejudice  against  an 
artificial  anus  may  he,  a  single  case  of  this  kind  will  convert 
him.  There  is  no  more  painful  death,  and  no  class  of  cases  in 
which  the  surgeon  appears  at  a  more  hopeless  disadvantage. 
I  have  successfully  combated  several  cases  of  serious  obstruc- 
tion by  medical  treatment,  and  even  in  almost  complete  ob- 
struction of  the  rectum  by  stricture  I  have  prolonged  life  till 
the  patient  died  of  other  causes;  but  I  know  now  that  an  early 
colotomy  would  have  been  much  better  surgery ;  and  I  shall 
never  cease  to  regret  one  case  in  particular  in  which  I  at- 
tended a  patient  with  cancer  of  the  prostate  from  its  first  dis- 
covery to  its  end  in  rupture  of  the  caput  coli.  At  the  autopsy 
there  were  secondary  deposits  in  the  liver  and  mesenteric 
glands,  and  the  abdomen  was  partially  filled  with  fluid,  so  that 
it  was  evident  that  even  colotomy  could  not  long  have  prolonged 
life;  but  it  would  at  least  have  given  a  less  painful  death. 

Colotomy  should  not,  however,  be  looked  upon  merely  as  a 
means  of  preventing  obstruction  or  of  overcoming  it  when 
actually  present.  The  operation  fulfils  other  indications,  and 
though  not  a  dangerous  one  when  done  early,  the  mortality 
is  greatly  increased  by  waiting  till  obstruction  has  set  in. 
Again  delay  may  cost  a  patient  his  life,  as  I  have  reason  to 
know  in  my  own  practice.  The  patient  was  a  young  physi- 
cian with  non-malignant  stricture  and  ulceration.  I  examined 
him  under  ether,  hoping  to  reach  the  stricture  and  divide  it, 
but  found  that  the  disease  extended  too  high  up  for  such 
treatment.  Colotomy  was  recommended  and  assented  to,  but 
as  the  man  was  no  worse  than  he  had  been  for  many  months, 
there  seemed  no  great  hurry,  and  the  operation  was  delayed. 
For  a  long  time  he  had  been  able  to  have  a  passage  only  by 
the  aid  of  strong  cathartics;  and  it  was  his  custom  to  take 
these  on  Saturday  night  and  devote  Sunday  to  unloading  the 


Stricture  of  the  Rectum.  35 

bowel.  As  lie  was  a  physician  and  an  intelligent  observer  of 
bis  own  case,  I  saw  no  harm  m  allowing  him  to  continue  the 
practice  a  few  weeks  longer,  but  the  result  was  disastrous. 
He  took  his  medicine  once  too  often,  the  distended  gut  gave 
way,  and  he  died  of  faecal  extravasation. 

The  hour  when  a  chronic  obstruction  will  change  into  a 
fatal  condition  can  never  be  foretold;  and  after  acute  obstruc- 
tion has  occurred  the  dangers  of  a  colotomy  are  greatly  in- 
creased. 

If  colotomy  is  to  be  done  it  should  be  done  early  in  order 
that  the  patient  may  be  spared  as  much  pain  and  the  growth 
of  the  disease  be  delayed  as  long  as  possible.  It  should  be  ' 
recommended  in  all  cases  of  non-malignant  stricture  and  ex- 
tensive ulceration  which  have  advanced  beyond  the  point 
where  proctotomy  and  dilatation  can  give  relief.  In  malig- 
nant  disease  the  chorice  between  colotomy  and  excision  may 
be  more  difficult  to  make.  All  cases  manifestly  beyond  the 
reach  of  excision  should  be  operated  upon  by  colotomy  at 
once;  but  each  surgeon  must  be  the  judge  of  what  cases  come 
under  this  category  and  of  how  much  danger  is  to  be  incurred 
for  the  hope  of  cure  which  excision  offers. 

The  range  of  applicability  of  colotomy  to  the  treatment  of 
non-malignant  affections  has  been  greatly  increased  by  the 
fact  that  the  opening  can  be  so  made  as  to  admit  of  its  easy 
subsequent  closure  should  it  be  advisable.  This  is  a  fact 
which  often  gives  great  comfort  to  the  patients  and  induces 
them  to  consent  to  what  might  otherwise  be  refused. 

Regarding  the  choice  of  operation  between  the  inguinal 
and  lumbar  region,  I  can  hardly  imagine  any  case  in  which 
the  old  lumbar  operation  is  preferable  to  the  inguinal.  The 
question  has  been  much  discussed,  and  recently  Bryant  with 
his  one  hundred  and  four  cases  has  said  all  that  can  be  said 
in  favor  of  the  lumbar  incision.  I  can  see  no  reason  from  his 
arguments  why  the  present  decided  preference  for  the  front 
operation  is  not  well-founded,  except  possibly  his  statement 
that  controlling  pressure  by  a  pad  can  be  more  firmly  applied 
in  the  other  incision,  and  I  have  found  no  difficulty  in  securing 
this  pressure  after  the  inguinal  operation.  As  regards  ease 
and  certainty  of  performance,  the  subsequent  cleanliness  of 
the  patient,  and  the  ability  to  care  for  the  opening,  all  the  ad- 
vantages are  in  favor  of  the  inguinal  opening.     The  dangers 


36  Stricture  of  the  Rectum. 

of  the  two  operations  are  about  the  same,  as  in  the  majority 
of  cases  the  peritoneum  is  opened  in  both  alike.    • 

In  performing'  the  left  inguinal  operation  no  particular 
previous  preparation  of  the  patient  is  necessary.  Many  of 
them  are  not  in  condition  to  have  the  bowel  thoroughly  emp- 
tied by  a  cathartic;  nor  is  there  anything  to  be  gained  by 
doing  so.  The  operation  often  has  to  be  done  on  very  short 
notice,  and  sometimes  in  the  midst  of  complete  intestinal  ob- 
struction. 

The  abdomen  should  be  shaved  and  thoroughly  cleansed 
on  the  day  before  the  operation,  if  possible;  and  should  be 
again  washed  with  bichloride  solution  and  ether  at  the  time 
of  the  operation.  It  should  then  be  covered  with  towels 
wrung  out  in  warm  carbolic  solution  at  all  parts  except 
where  the  incision  is  to  be  made.  It  is  needless  to  say  that 
the  comparative  immunity  with  which  the  abdomen  may  be 
opened  to-day  is  almost  entirely  due  to  antisepsis,  which  here 
should  be  of  the  most  perfect  kind. 

The  incision  which  I  practise  is  the  one  used  by  Cripps  and 
shown  in  the  cut,  except  that  I  do  not  find  it  necessar}7  to 
make  my  incision  quite  as  long  as  he  has  figured  (Fig.  11). 
An  imaginary  line  is  drawn  from  the  anterior  superior  spine 
to  the  umbilicus.  The  incision  should  cross  this  at  nearly 
right  angles  and  should  be  an  inch  and  a  half  distant  from 
the  anterior  spine.  The  incision  should  be  two  inches  in  length, 
and  it  may  be  made  an  inch  or  two  higher  or  lower  as  the 
operator  prefers.  If  there  be  any  reason  to  suppose  that  the 
disease  involves  the  sigmoid  flexure,  it  is  well  to  make  the  in- 
cision higher  up ;  and  in  this  way,  and  by  pulling  down  the 
upper  end  of  the  gut,  the  opening  in  the  latter  may  be  brought 
very  near  to  where  it  would  be  in  the  lumbar  operation. 

The  incision  is  carried  down  on  a  director  as  in  all  laparo- 
tomies till  the  peritoneum  is  reached,  and  before  this  is  opened 
the  cut  surface  must  be  thoroughly  dry  so  that  no  blood  will 
enter  the  abdominal  cavity.  As  a  rule  no  vessels  will  need 
tying,  and  after  a  few  minutes'  pressure  with  a  towel  the  peri- 
toneum may  be  opened  on  a  director  to  the  length  of  the  cu- 
taneous incision. 

Usually  a  coil  of  gut  presents  at  once  in  the  wound,  and 
this  must  be  carefully  examined  to  decide  whether  it  is  the 
part  wanted.     In  the  majority  of  cases  it  will  be  large  intes- 


Stricture  of  the  Rectum. 


37 


tine  and  may  be  fastened  at  once  into  the  wound,  but  this 
must  not  be  taken  for  granted  without  examining-  for  the 
longitudinal  bands  of  muscular  tissue  or  the  appendices  epi- 
ploicce  which  are  characteristic  of  the  larger  bowel. 

If  it  be  found  that  the  presenting  coil  is  small  intestine  it 
must  be  replaced  and  another  coil  brought  up  with  the  finger 


Fig.  11.— Incision  in  Inguinal  Colotomy  (Cripps). 

from  the  brim  of  the  pelvis.  When  the  gut  is  much  distended, 
difficulty  may  occur  at  this  stage  of  the  operation  from  pro- 
trusion, and  the  coil  may  require  considerable  pressure  to 
keep  it  in  the  abdomen.  No  violence  must  be  used,  for  a  dis- 
tended colon  in  a  case  of  obstruction  is  often  much  thinned, 
and  liable  to  rupture  with  slight  violence.  The  protrusion 
can  usually  be  easily  managed  by  the  pressure  of  a  flat  sponge 
or  the  closure  of  the  wound  with  the  fingers. 


38  Stricture  of  the  Rectum. 

The  selected  coil  is  next  to  be  drawn  downward  till  it  is 
held  firmly  by  the  mesentery  above,  and  fastened  to  the  edges 
of  the  wound  in  this  position.  In  several  of  my  later  cases  I 
have  used  a  hare-lip  pin,  as  the  first  step  in  fastening-  the  gut, 
and  I  am  much  pleased  with  the  results.  The  pin  is  passed  under 
the  coil  at  a  point  nearer  the  lower  than  the  upper  end  of  the 
wound  in  the  following  manner. 

It  is  entered  through  the  skin  at  the  junction  of  the  middle 
and  lower  third  of  the  incision  and  half  an  inch  from  the  edge, 
passed  through  the  edge  of  the  parietal  peritoneum  on  that 
side,  then  through  the  mesentery  close  to  the  gut  or  through 
the  muscular  wall  of  the  gut  itself  at  a  point  corresponding 
to  the  attachment  of  the  mesentery,  then  through  the  edge 
of  the  parietal  peritoneum  on  the  opposite  side,  and  finally 
out  through  the  skin  on  the  side  opposite  its  entrance. 

By  this  simple  manoeuvre  several  important  steps  in  the 
operation  are  accomplished  at  once.  The  gut  is  firmly  secured 
in  the  required  position  so  that  it  cannot  be  displaced  by  the 
patient  should  strainiwg  occur  under  the  anaesthetic  or  after, 
and  all  the  rest  of  the  operation  is  rendered  easy.  Again,  the 
sharpest  possible  spur  is  formed  in  the  posterior  wall  of  the 
gut,  at  the  junction  of  the  middle  and  lower  thirds. 

The  gut  is  next  stitched  to  the  edge  of  the  wound  all 
around,  each  suture  being  made  in  the  following  manner  (Fig. 
12).  A  small,  round,  slightly  curved  needle  is  used,  armed 
with  fairly  strong  silk.  The  needle  is  passed  through  the  skin 
an  eighth  of  an  inch  from  the  edge  of  the  incision,  then  through 
the  cut  edge  of  the  parietal  peritoneum  at  a  corresponding 
point,  then  through  the  muscular  wall  of  the  gut.  Care  must 
be  taken  not  to  perforate  the  whole  thickness  of  the  intestinal 
wall  so  that  fasces  may  escape  through  the  puncture,  and  yet 
sufficient  of  the  wall  must  be  included  in  the  stitch  to  secure 
it  firmly.  When  one  of  the  longitudinal  bands  comes  in  the 
right  place  or  can  be  brought  there,  it  is  well  to  pass  the 
sutures  of  one  side  through  this  band  for  additional  strength. 
The  sutures  should  also  pass  well  back  toward  the  mesenteric 
border  of  the  gut  in  order  that  at  least  two-thirds  of  the  cir- 
cumference may  be  outside  of  the  wound  when  all  of  the  su- 
tures have  been  passed.  Each  suture  may  be  tied  and  the  ends 
cut  off  as  it  is  passed. 

Generally  about  a  dozen  sutures  are  sufficient  to  give  close 


Stricture  of  the  Rectum. 


39 


approximation.  If  for  any  reason  the  gut  is  to  be  opened  at 
once,  this  number  may  be  increased  by  three  or  four  for  addi- 
tional security.  The  wound  is  then  dressed  first  with  a  piece 
of  protective,  then  with  a  layer  of  wet  bichloride  gauze,  then 
with  absorbent  cotton,  and,  finally,  with  a  broad  obstetrical 
bandage.  The  protective  is  important,  for  much  lymph  will 
be  thrown  out  around  the  wound  during  the  first  day,  and  the 
gauze,  if  put  next  to  the  wound,  will  be  found  so  closely  matted 
down  as  only  to  be  removed  with  great  difficulty. 

The  dressing  thus  applied  need  not  be  disturbed  till  the 


Fig.  12.     (After  Cripps.) 

end  of  the  third  day.  No  opium  need  be  given  unless  there  be 
some  special  indication;  and  the  patient  should  be  fed  upon 
milk. 

At  the  end  of  the  third  clay,  and  much  sooner  should  the 
patient  be  suffering  from  obstruction,  the  operation  may  be 
completed.  The  provisional  union  of  the  two  serous  surfaces 
which  shuts  off  the  peritoneal  cavity  occurs  in  a  few  hours; 
and  with  the  hare-lip  pin  to  support  the  gut  and  hold  it  im- 
movable, the  gut  may  be  opened  without  waiting  for  absolute 
union.  The  operation  is  completed  by  incising  the  gut  longi- 
tudinally with  a  sharp  bistoury,  and  paring  down  the  edges 
with  scissors  to  within  a  third  of  an  inch  of  the  skin  border. 
No  ether  is  necessary  and  no  pain  will  be  experienced.  There 
is  always  a  free  oozing  of  blood  for  a  few  minutes,  but  it  is 


40  Stricture  of  the  Rectum. 

seldom  necessary  to  tie  anything-.  The  pin  should  not  be  re- 
moved till  three  or  four  days  later,  and  the  sutures  may  be 
left  to  work  their  own  way  out. 

From  the  nature  of  the  operation  as  thus  performed  it  is 
evident  that  when  the  convex  surface  of  the  loop  of  gut  has 
been  cut  away,  two  openings  into  the  lumen  of  the  bowel  will 
exist — a  large  one  passing  into  the  upper  segment  and  a 
smaller  one  into  the  lower.  Between  these  openings  there  is  a 
sharp  spur  formed  by  the  posterior  border  of  the  gut  where 
it  has  been  sharply  bent  over  the  pin.  This  arrangement  has 
always  in  my  experience  been  effectual  in  preventing  any  pas- 
sage of  fgecal  matter  from  the  upper,  larger  opening,  into  the 
smaller,  lower  one — a  thing  which,  when  it  occurs,  detracts 
greatly  from  the  advantages  of  the  operation. 

There  is  a  great  advantage  in  all  cases  in  leaving  the  distal 
end  of  the  gut  open  at  both  ends  as  is  done  in  this  operation, 
for  by  inserting  a  syringe  into  the  wound  the  rectum  may  be 
thoroughly  washed  out  as  often  as  there  is  any  accumulation 
of  discharge. 

In  non-malignant  disease  it  is  well  in  the  operation  to  pre- 
serve as  much  of  the  circumference  of  the  gut  intact  as  possi- 
ble, in  case  it  should  in  the  future  be  thought  advisable  to 
close  the  artificial  anus.  The  only  difference  in  operating  to 
secure  this  end  is  to  include  less  of  the  circumference  of  the 
gut  in  the  row  of  sutures — making  the  opening  only  large 
enough  to  give  a  free  outlet. 

In  some  cases  after  the  operation  an  annoying  prolapse  of 
mucous  membrane  will  occur  from  the  upper  segment. 

This  has  never  been  an  element  of  trouble  in  any  of  my 
cases,  and  I  attribute  the  fact  to  the  drawing  down  of  the  up- 
per part  of  the  coil  firmly  before  attaching  it  to  the  skin. 

After  the  operation  the  action  of  the  bowel  may  be  left  to 
nature.  Sometimes  during  the  operation  scybalous  masses 
may  be  felt  in  the  sigmoid  flexure  and  these  are  an  additional 
indication  that  the  large  bowel  is  under  the  finger.  If  possi- 
ble I  always  prefer  to  have  these  masses  above  rather  than 
below  the  point  of  gut  to  be  opened,  for  their  evacuation  is 
then  easy;  and  when  in  the  distal  portion  they  cause  pain  by 
their  presence  and  may  have  to  be  washed  down  and  out  with 
the  syringe.  The  first  evacuation  may  occur  immediately  the 
bowel  is  opened  or  may  be  delayed  several  days  or  even  a 


Stricture  of  the  Rectum.  41 

week.  In  the  latter  cases  there  has  probably  been  chronic 
dilatation  and  obstruction,  and  some  time  is  required  for  the 
muscular  wall  to  recover  its  tone. 

With  regard  to  the  artificial  anus,  Cripps,  I  believe,  has  re- 
ported one  case  of  sphincteric  action,  but  it  is  safer  not  to 
promise  so  favorable  a  condition.  In  none  of  my  cases  have 
I  seen  anything  that  could  properly  be  called  voluntary  con- 
trol of  the  evacuations.  This  does  not,  however,  imply  that 
these  patients  are  troubled  with  a  constant  involuntary  evac- 
uation of  fasces,  for  such  is  not  the  case.  I  have  one  patient, 
indeed,  who  never  has  a  movement  more  than  once  a  week 
and  only  after  a  laxative.  When  the  patient  has  diarrhoea 
there  will  be  a  constant  discharge  of  fluid  fasces  till  the  diar- 
rhoea is  checked ;  but  under  ordinary  conditions  the  bowel  can 
be  trained  to  move  at  a  regular  time  each  day;  the  patient  is 
easily  able  to  care  for  the  evacuation,  and  is  then  comfortable 
for  the  balance  of  the  clay.  Both  men  and  women  are  able  to 
attend  to  their  duties  and  enjoy  life. 

In  the  way  of  a  dressing  a  truss  may  be  made  similar  to 
the  ordinary  one  for  inguinal  hernia  which  will  cause  sufficient 
pressure  to  prevent  the  escape  of  solid  fasces.  Most  of  my 
cases,  however,  are  more  comfortable  with  a  wide  bandage 
around  the  waist,  holding  a  piece  of  sheet  lint  upon  the  open- 
ing except  when  taking  active  exercise.  The  truss  should 
only  be  worn  during'  the  day. 


General  Treatment. 

In  the  treatment  of  non-malignant  stricture  and  ulcera- 
tion I  have  for  some  years  back  been  using  the  tincture  of 
arbor  vitas  in  large  doses  for  the  specific  effect  it  seems  in 
some  cases  to  exercise  upon  diseased  mucous  membranes. 
Where  there  is  much  ulceration  in  connection  with  the  stric- 
ture this  may  be  continued  for  many  weeks  with  occasional 
interruptions,  and  should  be  combined  with  local  applications 
to  the  diseased  surface.  After  division  of  the  stricture,  these 
agents  should  be  used  while  the  subsequent  dilatation  is  being 
practised;  and  under  their  combined  influence  the  discharge 
and  pain  will  often  either  entirely  cease  or  be  greatly  dimin- 
ished. 


42  Stricture  of  the  Rectum. 

In  malignant  disease  I  have  also  used  arbor  vita?  inter- 
nally, "but  have  seen  no  effect  from  it. 

Much  com(fort  may  be  given  patients  with  stricture  by  a 
proper  regulation  of  the  diet.  The  pain  of  the  disease  is  in 
great  measure  caused  by  defecation  and  the  object  should  be 
to  relieve  the  rectum  of  as  much  work  as  possible.  This  is 
best  acomplished  by  a  fluid  diet  of  the  most  concentrated 
form.  Milk,  strong  beef  soups,  and  eggs  give  the  greatest 
possible  nourishment  with  the  smallest  residue,  and  on  these 
the  patients  should  live.  In  this  way  constipation  is  produced 
and  this  is  best  relieved  by  the  use  of  the  long  tube  every  day 
or  every  alternate  day.  The  injections  must  be  carefully  di- 
rected by  the  physician  and  should  be  administered  through 
a  good-sized  soft  catheter  passed  above  the  stricture.  They 
should  consist  only  of  warm  water  or  of  olive  oil.  A  gentle 
laxative  such  as  the  compound  licorice  powder  may  be  also 
given  at  night  if  it  be  necessar3r.  The  injections  should  be 
large,  as  much  fluid  being  thrown  up  as  the  patient  can  well 
bear,  and  when  this  is  evacuated,  as  it  will  be  at  one  sitting, 
the  bowel  above  the  stricture  will  be  emptied  and  the  patient 
free  from  discomfort. 

Opium  is  a  thing  never  to  be  denied  these  sufferers  from 
malignant  disease,  but  to  be  employed  so  as  to  obtain  the 
greatest  amount  of  good.  Care  must  be  taken  not  to  culti- 
vate an  opium  habit,  for  when  once  this  is  formed  the  craving 
for  the  drug  will  induce  the  patient  to  counterfeit  pain ;  and 
before  the  end  of  the  disease  is  reached  all  benefit  to  be  derived 
from  the  anodyne  is  lost.  If  these  patients  are  taught  the 
use  of  the  hypodermic  syringe,  it  is  very  likely  to  be  abused. 

TABLE  OF   CASES. 

Whole  number 138 

Males 76 

Females 62 

Cancer 62 

Venereal 17 

Non- venereal 37 

Doubtful  (non-malignant) 11 

Congenital 6 

Due  to  pressure 3 

Spasmodic 1 


Stricture  of  the  Recttim. 


43 


TABLE   OF   OPERATIONS. 

Proctotomies. 


No. 


10 


11 


12 


Date. 

Name. 

Sex. 

Age. 

1878 

H. 

F. 

26 

1880 

F. 

F. 

30 

1881 

R. 

F. 

32 

1881 

P. 

F. 

31 

1881 

Z. 

F. 

27 

1882 

B. 

M. 

40 

1882 

P. 

F. 

38 

1883 

H. 

F. 

54 

1885 

P. 

M. 

50 

1886 

D. 

M. 

30 

1888 

L. 

F. 

34 

1888 

R. 

M. 

46 

Remarks. 

Tight  venereal  stricture ;  internal 
incision  without  drainage  followed 
by  pelvic  peritonitis.  Patient  in 
good  condition  four  years  later 

Slight  stricture ;  internal  incision. 
Case  lost  sight  of  a  month  later. . . . 

Non-venereal  stricture  and  fistulae  ; 
external  operation.  Patient  great- 
ly relieved  and  in  good  condition 
five  years  later 

Extensive  stricture  ;  external  oper- 
ation.    No  after-history 

Tight  and  extensive  stricture,  prob- 
ably venereal ,  external  operation. 
Six  months  later  no  recontraction. 

Old  venereal  stricture ;  external  oper- 
ation. Good  condition  one  year 
later 

Old  venereal  stricture  ;  external  oper- 
ation. Recontraction  from  neglect 
of  bougie  six  months  later 

Extensive  malignant  stricture ;  ex- 
ternal operation  ;  severe  secondary 
hemorrhage.  Death  eight  months 
after  operation 

Old  syphilitic  stricture ;  external 
operation  Result  good  as  long  as 
bougie  was  used 

Extensive  malignant  disease.  Died 
on  seventh  day  with  symptoms  of 
peritonitis  and  exhaustion 

Non-malignant  stricture ;  internal 
operation  with  drainage.  No 
symptoms  two  years  and  a  half 
later,  except  tendency  to  contract 
when  bougie  has  not  been  used  for 
some  months  

Non-malignant  stricture  and  fistulae 
internal   operation  with  drainage 
posteriorly,  and  complete  division 
of  stricture  with  sphincters  through 
a  fistulous  track  anteriorly 


Result. 


Recovery. 


Recovery. 


Recovery. 


Recovery. 


Recovery. 


Recovery. 


Recovery. 


Recovery. 


Recovery. 


Death. 


Recovery. 


Recovery. 


44 


Stricture  of  the  Rectiun. 
Proctotomies. — (Continued.) 


No. 

Date. 

Name. 

Sex. 

Age. 
34 

Remarks. 

Result. 

13 

1888 

A. 

F. 

Malignant  stricture  and  intestinal 

obstruction  ;  external  operation. 

Death  from  shock  in  eight  hours. 

Death. 

14 

1889 

B. 

M. 

28 

Stricture  from  hemorrhoidal  ulcer- 
ation ;    internal  operation  with 
drainage.     No  recontraction  one 
year  later 

Recovery. 

15 

1889 

P. 

F. 

35 

Slight  stricture ;    internal    opera- 

tion with  drainage.      No  subse- 

quent treatment.    Case  lost  sight 

of  after  three  weeks 

Recovery. 

16 

1890 

H. 

M. 

57 

Very     extensive    non  -  malignant 

stricture  of  nearly  thirty  years' 

standing      Under  ether  the  dis- 

ease was  found  to    extend    too 

high  for  safe  posterior  division, 

and  the  upper  portion  was  sub- 

sequently treated  by  dilatation. 

Four  months  after  operation  the 

patient  was  having  one  natural 

daily  passage,  was  using  No.  11 

bougie  without   pain,    and   was 

more  comfortable  than  for.  many 

Recovery. 

17 

1890 

N. 

F. 

25 

Tight  non-malignant  stricture  ;  in- 
ternal   incision    and     drainage. 
Now  under  treatment 

Recovery. 

18 

1890 

S. 

M. 

45 

Tight  but  not  very  extensive  stric- 

ture,   perhaps    congenital.      No 

other  cause  discoverable.    Inter- 

nal incision  and  drainage.    Large 

perirectal  cellulitis  on  the  third 

day.  Free  incisions.  Patient  lived 

three  months  and  a  half,  and  died 

finally  worn  out  by  the  suppura- 

tion.    A  few  days  before  death 

the  abscess,  which  had  extended 

deep  into  the  pelvis,  opened  into 

the  bladder,  and  for  this  compli- 

cation colotomy  was  done 

Death, 

19 

1891 

N. 

M. 

40 

Tubercular  ulceration  and    stric- 
ture.    Subsequent  extirpation. . 

Recovery. 

20 

1891 

O'C. 

M. 

23 

Annular  stricture  low  down.    Pos- 
terior   median    incision    carried 
through  sphincters 

Recovery. 

Stricture  of  the  Rectum 
Proctotomies. — (Continued.) 


45' 


No, 


21 


22 


23 


Date. 

Name. 

Sex. 

Age. 
35 

1891 

R. 

w. 

1891 

P.  Gr. 

M. 



189; 

L. 

W. 

35 

Remarks. 


Tight  annular  stricture  following 
extirpation.     Posterior  deep  in 
eision 


Tight  and  extensive  stricture,  with 
numerous  fistulas.  Two  inches 
of  gut  involved,  commencing  at 
one  inch  from  anus.  Posterior 
median  incision %  . . 


Impervious  congenital  occlusion 
at  one  and  a  half  inches,  with 
second  constriction  at  three 
inches,  opening  only  admitting 
uterine  sound . , 


Result. 


Recovery. 


Recovery. 


Recovery. 


Inguinal  Colotomies. 


1888 


1889 


1889 


1889 


1889 


1890 


McK. 


F. 


C.      M 


M. 


P. 


M. 


Pv. 


M. 


M. 


M. 


50 


58 


31 


49 


35 


42 


Acute  obstruction  from  pressure  of 
cancerous  mass  opposite  promon- 
tory of  sacrum.  Intestine  much 
congested  and  abdomen  full  of 
fluid.     Lived  eighteen  months. . . 

Extensive  non-malignant  ulcera- 
tion, stricture,  and  fistulse.  Great 
relief.     Alive  two  years  later. . 

Intestino-vesical  fistula  and  cancer 
of  the  rectum.  Immediate  re- 
lief of  vesical  symptoms 

Extensive  malignant  disease.  Im- 
mediate relief  to  worst  symp 
toms.     Alive  one  year  later 


Extensive  cancerous  obstruction 
and  great  exhaustion.  Death 
fifty-two  hours  after  operation,  of 
exhaustion,  without  shock 


Cancerous  stricture  ;  operation  fol- 
lowed by  sufficient  relief  to  allow 
patient  to  get  out  of  bed  and  in- 
to the  street  for  exercise.  Alive 
six  months  later 


Rectum  occluded  by  pressure  of 
pelvic  abscess,  added  to  old  stric- 
ture and  ulceration.  One  month 
after  operation  patient  had 
gained  twenty  pounds  in  weight, 
and  was  more  comfortable  than 
at  any  time  since  disease  began. 


Recovery. 


Recovery. 


Recoverv. 


Recovery. 


Death. 


Recovery. 


Recovery. 


46 


Stricture  of  the  Rectum. 
Inguinal  Colotomies. — (Continued.) 


No.    Date. 


1890 


10 


11 


1890 


1890 


1890 


12 
13 

14 

15 

1G 

17 


1890 
1890 

1891 

1891 

1891 

1891 


Name. 

Sex. 
F. 

Age. 
60 

F. 

Minor. 

M. 

25 

Soule. 

M. 

45 

- 

M. 

7m's 

Grogin. 

F. 

21 

Mooney. 

M. 

35 

Kilbride. 

M. 

50 

Nye. 

M. 

40 

Platte. 

M. 

45 

R. 

W. 

45 

Remarks. 


Tight  cancerous  stricture  and 
chronic  obstruction  ;  abdom- 
inal glands  all  involved  ; 
forty-eight  hours  after  opera- 
tion patient  suddenly  taken 
with  symptoms  of  collapse, 
ending  fatally  in  a  few  hours; 
autopsy  revealed  an  obstruc- 
tion by  a  mass  of  cancerous 
mesentery  at  the  splenic  flex- 
ure of  the  colon,  which  had 
occurred  since  the  operation. 

Extensive  ulceration  and  tight 
stricture  at  limit  of  digital 
examination,  probably  due 
to  habitual  constipation... 


(Case  No.  18  of  Proctotomies.) 
Operation  done  to  relieve 
recto  -  vesical  fistula  a  few 
hours  before  death  from  ex- 
haustion  


Imperforate  anus  operated  on 
by  deep  perineal  incision  at 
birth.  Child  greatly  emaci- 
ated, and  with  large  mass  of 
impermeable  stricture  tissue 
extending  from  skin  one  and 
a  half  inches  into  pelvis 


Non-malignant  ulceration  be 
ginning  at  anus  and  extend 
ing  high  up  rectum 

Scirrhus  involving  whole  rec 
turn  and  skin  of  anus  and 
buttocks.  General  glandular 
involvement 


Result. 


Cancer  of  sigmoid  flexure  and 
whole  of  descending  colon, 
with  involvement  of  mesen- 
tery. Opening  made  in  trans- 
verse colon 


Dysenteric  ulceration  and  stric- 
ture  at    eight    inches    from 


Cancer  of  anus  and  rectum  ex- 
tending: six  inches 


Death. 


Recovery. 


Death. 


Cancer,   return  after   extirpa- 
tion. (Case  No.  8  of  Excisions.) 


Recovery. 
Recovery. 

Recovery. 

Recovery. 

Recovery. 
Recovery. 
Recovery. 


Stricture  of  the  Rectum. 
Inguinal  Colotomies. — (Continued.) 


47 


No. 


18 


Date. 


1891 


Name. 


19      1891 


20 


21 


22 


23 


24 


1891 


1891 


1891 


1891 


1891 


E. 


Ball. 


Gribbs. 


Rea. 


Parman. 


Reeves. 


Charles. 


25     1891 


26 


1891 


Walsh. 


Sex.  Age 


Gallagh'r   M 


W. 

W. 
M. 

W. 
M. 

W. 

M. 


M. 


26 


53 


51 


40 


35 


32 


32 


03 


Remarks. 


Non-malignant  ulceration 
covering  lower  four  inches  of 
rectum 


Stricture  for  thirty-five  years 
following  old  pelvic  cellulitis. 

Cancer  involving  base  of  blad- 
der ;  commencing  opposite 
prostate,  and  extending  up- 
ward.    Immovable 


Cancer,  which  had  twice  been 
extirpated,  and  once  divided, 
in  median  line 


61    Cancer  at  upper  part  of  rectum; 
i'     large  immovable  fungous 
mass,  with  secondary  growths 
around 


Rectum  nearly  closed  by  exu 
dation  of  old  pelvic  cellulitis, 
with  abscess 


Dysenteric  stricture  and  exten 
sive  ulceration  involving  en 
tire  circumference  of  gut  for 
several  inches 


Cancer,     with   obstruction 
two  weeks'  duration 


of 


Cancer  of  upper  rectum   and 
pelvis  ... 


Result. 


Recovery. 
Recovery. 


Recovery. 


Recovery. 


Recovery. 


Recovery. 


Recovery. 
Recovery. 


Recovery. 


Excisions. 


1884 


M. 


1887 


1887 


W. 


F. 


M. 

55 

M. 

64 

M. 

69 

Excision  of  cancerous  mass  on 
anterior  wall  of  rectum  three 
inches  from  anus,  involving 
peritonitis.  Death  fifty-two 
hours  after  operation,  from 
exhaustion 

Non-malignant  stricture  and 
large  polypus  filling  rectum. 
Result  good  as  regards  recon- 
traction  and  sphincteric  con- 
trol  

Circumscribed  cancerous 
growth  on  anterior  wall  op- 
posite prostate 


Death. 


Recovery. 


Recovery. 


48 


Stricture  of  the  Rectum.. 
Excisions. — (Continued.) 


No.    Date.         Name.        Sex. 


1889 


1889 


1890 


1890 


B. 


R. 


R. 


P. 


F. 


M. 


M. 


1890 


Richards. 


10 


1891 


1891 


Negro. 


Piatt. 


M. 


M. 


11 


1891 


B. 


M. 


Remarks. 


Result. 


'24 


38 


58 


50 


40 


40 


45 


69 


Extensive  non-malignant  stric- 
ture ;  complete  circular  re- 
section ;  subsequent  opera! 
tion  for  incontinence  suc-l 
cessf ul.     ±so  recontraction. . .  Recovery. 

Complete  circular  resection  for 
cancer  ;  vagina  opened  ;  re- 
turn of  two  nodules  in  the 
recto  -  vaginal  septum  six 
months  later.  Second  opera-| 
tion  for  these  also  successful.  Recovery. 


Xon-malignant  stricture:  com- 
plete circular  resection.  No 
recontraction,  and  but  slight 
sphincteric  control 


Cancerous  stricture  with 
chronic  obstruction ;  com- 
plete circular  excision;  gut 
above  the  disease  very  much 
distended  and  ulcerated 
Collapse  from  rupture  of  sig 
moid  flexure  above  the  opera- 
tion fatal  in  twelve  hours. . . 

Scirrhus  involving  anus  and 
recto -vaginal  septum.  Re- 
moval of  almost  entire  sep- 
tum, leaving  rectum  and  va- 
gina one  common  cavity. 
Good  fecal  control  from 
sphincter  vaginae.  Return  in 
three  months  ;  colotomy. . . . 


Recovery. 


Death. 


Recovery. 


Tubercular  ulceration  of  anusj 
and  rectum.  Two  and  a  half  I 
inches  of  gut  removed Recovery. 

Case  previously  colotomized ; 
Kraske's  incision.  Extirpa- 
tion of  entire  rectum  and 
much  peri-rectal  tissue. 
Great  shock.  Death  in 
twelve  hours  from  shock Death. 

Circumscribed  mass  on  right 
side.  Two-thirds  of  circum- 
ference of  gut  removed  for 
lower  three  inches Recovery. 


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